- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.36 / $1,190.36 / $1,897.16
| Facility | | $1,190.36 | $1,190.36 | $1,897.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.36 / $1,357.77 / $1,897.16
| Professional | | $1,190.36 | $1,357.77 | $1,897.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.03 / $1,646.03 / $1,646.03
| Facility | | $1,646.03 | $1,646.03 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.03 / $1,646.03 / $1,646.03
| Professional | | $1,646.03 | $1,646.03 | $1,646.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.28 / $1,327.28 / $1,327.28
| Facility | | $1,327.28 | $1,327.28 | $1,327.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.91 / $968.91 / $1,327.28
| Professional | | $968.91 | $968.91 | $1,327.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,407.34 / $2,832.16 / $3,398.59
| Facility | | $2,407.34 | $2,832.16 | $3,398.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.47 / $1,026.64 / $1,632.96
| Professional | | $706.47 | $1,026.64 | $1,632.96 |