- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,145.41 / $1,145.41 / $1,789.70
| Facility | | $1,145.41 | $1,145.41 | $1,789.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.20 / $1,665.47 / $1,789.70
| Professional | | $1,075.20 | $1,665.47 | $1,789.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,583.86 / $1,583.86 / $1,583.86
| Facility | | $1,583.86 | $1,583.86 | $1,583.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.86 / $1,583.86 / $1,583.86
| Professional | | $1,583.86 | $1,583.86 | $1,583.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.82 / $1,367.82 / $1,367.82
| Facility | | $1,367.82 | $1,367.82 | $1,367.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.51 / $998.51 / $1,367.82
| Professional | | $998.51 | $998.51 | $1,367.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $649.48 / $1,347.44 / $1,571.29
| Facility | | $649.48 | $1,347.44 | $1,571.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.78 / $1,019.68 / $1,612.86
| Professional | | $679.78 | $1,019.68 | $1,612.86 |