- 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
- $1,443.96 / $1,461.57 / $2,434.92
| Professional | | $1,443.96 | $1,461.57 | $2,434.92 |
- 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 / $1,012.40
| Professional | | $410.35 | $410.35 | $1,012.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.43 / $639.41 / $831.23
| Professional | | $396.43 | $639.41 | $831.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.05 / $613.11 / $919.66
| Professional | | $487.05 | $613.11 | $919.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.22 / $385.44 / $598.70
| Professional | | $359.22 | $385.44 | $598.70 |