- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,338.46 / $1,338.46 / $2,048.62
| Facility | | $1,338.46 | $1,338.46 | $2,048.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.38 / $1,338.46 / $1,609.69
| Professional | | $1,216.38 | $1,338.46 | $1,609.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.75 / $1,586.51 / $1,728.53
| Facility | | $1,391.75 | $1,586.51 | $1,728.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.41 / $1,536.47 / $1,536.47
| Professional | | $788.41 | $1,536.47 | $1,536.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.88 / $1,491.88 / $1,491.88
| Facility | | $1,491.88 | $1,491.88 | $1,491.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.33 / $1,785.89 / $3,659.63
| Professional | | $1,234.33 | $1,785.89 | $3,659.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.31 / $1,424.77 / $2,115.62
| Professional | | $1,024.31 | $1,424.77 | $2,115.62 |