- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.79 / $1,745.63 / $2,658.72
| Facility | | $1,342.79 | $1,745.63 | $2,658.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,342.79 / $1,342.79
| Professional | | $1,294.26 | $1,342.79 | $1,342.79 |
- 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
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.60 / $6,076.00 / $6,076.00
| Facility | | $1,485.60 | $6,076.00 | $6,076.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.15 / $1,388.63 / $1,388.63
| Professional | | $1,375.15 | $1,388.63 | $1,388.63 |