- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,065.19 / $1,065.19 / $1,697.65
| Facility | | $1,065.19 | $1,065.19 | $1,697.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.04 / $1,135.03 / $1,697.65
| Professional | | $903.04 | $1,135.03 | $1,697.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.93 / $1,472.93 / $1,472.93
| Facility | | $1,472.93 | $1,472.93 | $1,472.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.93 / $1,472.93 / $1,472.93
| Professional | | $1,472.93 | $1,472.93 | $1,472.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.36 / $1,030.36 / $1,030.36
| Facility | | $1,030.36 | $1,030.36 | $1,030.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.17 / $752.17 / $1,497.22
| Professional | | $752.17 | $752.17 | $1,497.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.94 / $884.26 / $1,292.38
| Professional | | $530.94 | $884.26 | $1,292.38 |