- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.55 / $1,320.55 / $2,014.08
| Facility | | $1,320.55 | $1,320.55 | $2,014.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.11 / $1,320.55 / $1,581.74
| Professional | | $1,106.11 | $1,320.55 | $1,581.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.07 / $1,559.75 / $1,699.38
| Facility | | $1,367.07 | $1,559.75 | $1,699.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.07 / $1,510.56 / $1,510.56
| Professional | | $775.07 | $1,510.56 | $1,510.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.94 / $1,463.94 / $1,463.94
| Facility | | $1,463.94 | $1,463.94 | $1,463.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.09 / $1,742.35 / $3,631.41
| Professional | | $1,110.09 | $1,742.35 | $3,631.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.48 / $1,339.30 / $2,078.23
| Professional | | $1,004.48 | $1,339.30 | $2,078.23 |