- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.43 / $1,310.43 / $2,607.76
| Facility | | $1,310.43 | $1,310.43 | $2,607.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.43 / $1,310.43 / $1,310.43
| Professional | | $1,310.43 | $1,310.43 | $1,310.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.58 / $1,429.07 / $1,429.07
| Professional | | $523.58 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.27 / $1,375.95 / $1,873.91
| Facility | | $653.27 | $1,375.95 | $1,873.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $1,388.63
| Professional | | $1,388.63 | $1,388.63 | $1,388.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $1,388.63
| Professional | | $1,388.63 | $1,388.63 | $1,388.63 |