- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,479.11 / $1,949.84
| Facility | | $1,412.54 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $1,412.54
| Professional | | $1,122.02 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $954.99
| Facility | | $660.69 | $812.83 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,548.82
| Professional | | $1,412.54 | $1,412.54 | $1,548.82 |