- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.08 / $1,052.08 / $1,052.08
| Facility | | $1,052.08 | $1,052.08 | $1,052.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.10 / $1,052.08 / $2,159.84
| Professional | | $687.10 | $1,052.08 | $2,159.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.44 / $702.94 / $1,359.70
| Facility | | $534.44 | $702.94 | $1,359.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.93 / $1,630.72 / $2,051.56
| Facility | | $941.93 | $1,630.72 | $2,051.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.01 / $1,463.01 / $1,463.01
| Professional | | $1,463.01 | $1,463.01 | $1,463.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.10 / $921.16 / $921.16
| Facility | | $900.10 | $921.16 | $921.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.36 / $875.85 / $921.16
| Professional | | $817.36 | $875.85 | $921.16 |