- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.19 / $2,470.85 / $2,740.89
| Facility | | $1,350.19 | $2,470.85 | $2,740.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.65 / $1,552.72 / $2,740.89
| Professional | | $1,066.65 | $1,552.72 | $2,740.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.24 / $1,665.24 / $1,665.24
| Facility | | $1,665.24 | $1,665.24 | $1,665.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.24 / $1,665.24 / $1,665.24
| Professional | | $1,665.24 | $1,665.24 | $1,665.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $877.62 / $921.50 / $1,132.13
| Facility | | $877.62 | $921.50 | $1,132.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.85 / $1,040.13 / $1,939.55
| Professional | | $577.85 | $1,040.13 | $1,939.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.08 / $810.11 / $2,304.73
| Professional | | $567.08 | $810.11 | $2,304.73 |