- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.57 / $1,461.57 / $1,461.57
| Facility | | $1,461.57 | $1,461.57 | $1,461.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.35 / $1,461.57 / $1,496.79
| Professional | | $1,426.35 | $1,461.57 | $1,496.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.71 / $1,540.81 / $4,681.13
| Facility | | $1,342.71 | $1,540.81 | $4,681.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.96 / $1,383.82 / $1,467.44
| Professional | | $478.96 | $1,383.82 | $1,467.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $482.77 / $621.27
| Facility | | $482.77 | $482.77 | $621.27 |
- 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
- $301.80 / $385.44 / $642.40
| Professional | | $301.80 | $385.44 | $642.40 |