- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,899.08 / $2,170.37 / $2,171.33
| Facility | | $1,899.08 | $2,170.37 | $2,171.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,899.08 / $2,441.67
| Professional | | $1,808.65 | $1,899.08 | $2,441.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.59 / $1,233.59 / $1,356.96
| Facility | | $1,233.59 | $1,233.59 | $1,356.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.26 / $1,808.65 / $1,808.65
| Facility | | $1,115.26 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,808.65
| Professional | | $1,808.65 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $2,025.69
| Professional | | $1,808.65 | $1,808.65 | $2,025.69 |