- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,326.61 / $1,941.38 / $1,941.38
| Facility | | $1,326.61 | $1,941.38 | $1,941.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.61 / $1,375.15 / $1,941.38
| Professional | | $1,326.61 | $1,375.15 | $1,941.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.48 / $1,188.48 / $1,307.33
| Facility | | $1,188.48 | $1,188.48 | $1,307.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $884.81 / $1,429.07 / $1,429.07
| Facility | | $884.81 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.08 / $1,388.63 / $1,805.22
| Professional | | $1,333.08 | $1,388.63 | $1,805.22 |