- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,737.80
| Facility | | $1,096.48 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $1,737.80
| Professional | | $870.96 | $1,023.29 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,202.26
| Professional | | $891.25 | $891.25 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,548.82 / $2,344.23
| Facility | | $575.44 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $933.25 / $1,318.26
| Professional | | $575.44 | $933.25 | $1,318.26 |