- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,199.65 / $1,755.59 / $1,755.59
| Facility | | $1,199.65 | $1,755.59 | $1,755.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.65 / $1,243.54 / $1,755.59
| Professional | | $1,199.65 | $1,243.54 | $1,755.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,034.26
| Facility | | $1,000.00 | $1,000.00 | $1,034.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,496.39
| Facility | | $1,243.54 | $1,243.54 | $1,496.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,243.54
| Professional | | $1,243.54 | $1,243.54 | $1,243.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.39 / $1,219.16 / $1,560.52
| Professional | | $1,170.39 | $1,219.16 | $1,560.52 |