- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.57 / $1,461.57 / $1,496.79
| Facility | | $1,461.57 | $1,461.57 | $1,496.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.74 / $1,461.57 / $1,496.79
| Professional | | $1,408.74 | $1,461.57 | $1,496.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,599.51 / $2,327.07 / $4,534.68
| Facility | | $1,599.51 | $2,327.07 | $4,534.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.96 / $700.28 / $1,467.44
| Professional | | $478.96 | $700.28 | $1,467.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $482.77 / $482.77
| Facility | | $482.77 | $482.77 | $482.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.35 / $410.35 / $1,002.38
| Professional | | $410.35 | $410.35 | $1,002.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.57 / $433.70 / $653.97
| Professional | | $327.57 | $433.70 | $653.97 |