- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,595.46 / $1,595.46 / $2,542.76
| Facility | | $1,595.46 | $1,595.46 | $2,542.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.15 / $1,819.82 / $2,542.76
| Professional | | $1,413.15 | $1,819.82 | $2,542.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.19 / $2,206.19 / $2,206.19
| Facility | | $2,206.19 | $2,206.19 | $2,206.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.19 / $2,206.19 / $2,206.19
| Professional | | $2,206.19 | $2,206.19 | $2,206.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,549.06 / $1,549.06 / $1,549.06
| Facility | | $1,549.06 | $1,549.06 | $1,549.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.81 / $1,130.81 / $1,549.06
| Professional | | $1,130.81 | $1,130.81 | $1,549.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $1,324.47 / $2,120.14
| Professional | | $782.55 | $1,324.47 | $2,120.14 |