- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,145.58 / $1,145.58 / $1,374.71
| Facility | | $1,145.58 | $1,145.58 | $1,374.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.82 / $1,145.58 / $1,283.70
| Professional | | $922.82 | $1,145.58 | $1,283.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.53 / $1,031.53 / $1,602.52
| Professional | | $1,031.53 | $1,031.53 | $1,602.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.57 / $936.57 / $936.57
| Facility | | $936.57 | $936.57 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.08 / $796.08 / $936.57
| Professional | | $796.08 | $796.08 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.40 / $101.87 / $513.40
| Professional | | $53.40 | $101.87 | $513.40 |