- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.15 / $1,375.15 / $1,617.82
| Facility | | $1,375.15 | $1,375.15 | $1,617.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.79 / $1,375.15 / $1,375.15
| Professional | | $1,342.79 | $1,375.15 | $1,375.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $481.53 / $497.22 / $870.14
| Facility | | $481.53 | $497.22 | $870.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.87 / $1,429.07 / $1,429.07
| Facility | | $643.87 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $2,692.55
| Professional | | $1,429.07 | $1,429.07 | $2,692.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.97 / $1,388.63 / $1,617.82
| Professional | | $1,346.97 | $1,388.63 | $1,617.82 |