- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,882.73
| Facility | | $1,116.58 | $1,116.58 | $1,882.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,563.91 / $1,882.73
| Professional | | $1,116.58 | $1,563.91 | $1,882.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,063.46 / $1,702.86 / $2,264.54
| Facility | | $1,063.46 | $1,702.86 | $2,264.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,563.91 / $1,882.73
| Professional | | $1,116.58 | $1,563.91 | $1,882.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.82 / $859.28 / $1,432.13
| Professional | | $721.82 | $859.28 | $1,432.13 |