- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,657.34 / $1,690.16
| Facility | | $1,640.93 | $1,657.34 | $1,690.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,657.34 / $1,805.02
| Professional | | $1,640.93 | $1,657.34 | $1,805.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.37 / $354.37 / $531.55
| Facility | | $354.37 | $354.37 | $531.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.37 / $354.37 / $361.46
| Professional | | $354.37 | $354.37 | $361.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.37 / $121.37 / $121.37
| Facility | | $121.37 | $121.37 | $121.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.05 / $1,548.05 / $1,640.93
| Facility | | $1,548.05 | $1,548.05 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.08 / $1,640.93 / $1,809.13
| Professional | | $1,510.08 | $1,640.93 | $1,809.13 |