- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,459.17 / $1,459.17
| Facility | | $1,400.00 | $1,459.17 | $1,459.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.72 / $1,527.81 / $1,694.25
| Professional | | $1,356.72 | $1,527.81 | $1,694.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.14 / $1,834.76 / $1,999.01
| Facility | | $1,620.14 | $1,834.76 | $1,999.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.90 / $1,776.90 / $1,776.90
| Professional | | $1,776.90 | $1,776.90 | $1,776.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.74 / $1,776.37 / $2,429.75
| Professional | | $1,235.74 | $1,776.37 | $2,429.75 |