- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.17 / $1,632.17 / $2,550.27
| Facility | | $1,632.17 | $1,632.17 | $2,550.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.17 / $2,550.27 / $2,918.41
| Professional | | $1,632.17 | $2,550.27 | $2,918.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,256.94 / $2,256.94 / $2,256.94
| Facility | | $2,256.94 | $2,256.94 | $2,256.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.94 / $2,256.94 / $2,256.94
| Professional | | $2,256.94 | $2,256.94 | $2,256.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.89 / $1,819.89 / $1,819.89
| Facility | | $1,819.89 | $1,819.89 | $1,819.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.52 / $1,328.52 / $1,819.89
| Professional | | $1,328.52 | $1,328.52 | $1,819.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,776.27 / $1,776.27 / $1,776.27
| Facility | | $1,776.27 | $1,776.27 | $1,776.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.67 / $1,453.01 / $2,298.27
| Professional | | $968.67 | $1,453.01 | $2,298.27 |