- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.58 / $1,030.58 / $1,642.51
| Facility | | $1,030.58 | $1,030.58 | $1,642.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.04 / $1,175.52 / $1,642.51
| Professional | | $971.04 | $1,175.52 | $1,642.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,425.08 / $1,425.08 / $1,425.08
| Facility | | $1,425.08 | $1,425.08 | $1,425.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.08 / $1,425.08 / $1,425.08
| Professional | | $1,425.08 | $1,425.08 | $1,425.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $1,108.41 / $1,108.41
| Facility | | $1,108.41 | $1,108.41 | $1,108.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.14 / $809.14 / $1,108.41
| Professional | | $809.14 | $809.14 | $1,108.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.04 / $855.53 / $1,369.51
| Professional | | $581.04 | $855.53 | $1,369.51 |