- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.53 / $1,122.53 / $1,753.95
| Facility | | $1,122.53 | $1,122.53 | $1,753.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.74 / $1,683.79 / $2,037.47
| Professional | | $1,095.74 | $1,683.79 | $2,037.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.22 / $1,552.22 / $1,552.22
| Facility | | $1,552.22 | $1,552.22 | $1,552.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.22 / $1,552.22 / $1,552.22
| Professional | | $1,552.22 | $1,552.22 | $1,552.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.58 / $1,573.58 / $1,573.58
| Facility | | $1,573.58 | $1,573.58 | $1,573.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.71 / $1,148.71 / $1,573.58
| Professional | | $1,148.71 | $1,148.71 | $1,573.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.08 / $1,261.08 / $1,261.08
| Facility | | $1,261.08 | $1,261.08 | $1,261.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.78 / $999.31 / $1,402.54
| Professional | | $606.78 | $999.31 | $1,402.54 |