- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.82 / $1,273.82 / $2,030.15
| Facility | | $1,273.82 | $1,273.82 | $2,030.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.09 / $1,311.47 / $2,030.15
| Professional | | $1,049.09 | $1,311.47 | $2,030.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,761.42 / $1,761.42 / $1,761.42
| Facility | | $1,761.42 | $1,761.42 | $1,761.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.42 / $1,761.42 / $1,761.42
| Professional | | $1,761.42 | $1,761.42 | $1,761.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.41 / $1,179.41 / $1,179.41
| Facility | | $1,179.41 | $1,179.41 | $1,179.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.97 / $860.97 / $1,179.41
| Professional | | $860.97 | $860.97 | $1,179.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.76 / $1,057.45 / $1,692.72
| Professional | | $627.76 | $1,057.45 | $1,692.72 |