- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,294.26 / $2,912.08
| Facility | | $1,294.26 | $1,294.26 | $2,912.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,617.82 / $1,617.82
| Professional | | $1,294.26 | $1,617.82 | $1,617.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.13 / $1,456.13 / $1,820.16
| Professional | | $1,456.13 | $1,456.13 | $1,820.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.93 / $1,617.82 / $2,200.23
| Facility | | $837.93 | $1,617.82 | $2,200.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $1,508.12
| Professional | | $1,388.63 | $1,388.63 | $1,508.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.33 / $1,388.63 / $1,508.12
| Professional | | $1,180.33 | $1,388.63 | $1,508.12 |