- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.77 / $1,644.77 / $2,271.34
| Facility | | $1,644.77 | $1,644.77 | $2,271.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.22 / $1,644.77 / $1,644.77
| Professional | | $783.22 | $1,644.77 | $1,644.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.49 / $984.25 / $2,341.83
| Facility | | $848.49 | $984.25 | $2,341.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.02 / $1,500.02 / $1,875.02
| Professional | | $1,500.02 | $1,500.02 | $1,875.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.83 / $1,174.83 / $1,174.83
| Facility | | $1,174.83 | $1,174.83 | $1,174.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.26 / $783.22 / $1,305.36
| Professional | | $548.26 | $783.22 | $1,305.36 |