- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,412.54
| Facility | | $1,023.29 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,691.53
| Facility | | $1,288.25 | $1,698.24 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $575.44 / $1,148.15
| Facility | | $436.52 | $575.44 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $616.60 / $1,174.90
| Facility | | $436.52 | $616.60 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,096.48 / $1,584.89
| Professional | | $630.96 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $3,467.37
| Facility | | $1,047.13 | $1,047.13 | $3,467.37 |