- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,194.76 / $1,194.76 / $1,866.82
| Facility | | $1,194.76 | $1,194.76 | $1,866.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.76 / $1,838.35 / $2,268.11
| Professional | | $1,194.76 | $1,838.35 | $2,268.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.09 / $1,652.09 / $1,652.09
| Facility | | $1,652.09 | $1,652.09 | $1,652.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.09 / $1,652.09 / $1,652.09
| Professional | | $1,652.09 | $1,652.09 | $1,652.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,620.00 / $1,620.00
| Facility | | $1,620.00 | $1,620.00 | $1,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.59 / $1,182.59 / $1,620.00
| Professional | | $1,182.59 | $1,182.59 | $1,620.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.94 / $2,783.46 / $3,340.15
| Facility | | $2,365.94 | $2,783.46 | $3,340.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.32 / $1,063.60 / $1,604.89
| Professional | | $694.32 | $1,063.60 | $1,604.89 |