- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.73 / $1,277.73 / $1,996.45
| Facility | | $1,277.73 | $1,277.73 | $1,996.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.73 / $1,996.45 / $2,513.48
| Professional | | $1,277.73 | $1,996.45 | $2,513.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,766.83 / $1,766.83 / $1,766.83
| Facility | | $1,766.83 | $1,766.83 | $1,766.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.83 / $1,766.83 / $1,766.83
| Professional | | $1,766.83 | $1,766.83 | $1,766.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $1,424.68
| Facility | | $1,424.68 | $1,424.68 | $1,424.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $2,170.14
| Professional | | $1,040.02 | $1,040.02 | $2,170.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.31 / $1,137.47 / $1,752.80
| Professional | | $758.31 | $1,137.47 | $1,752.80 |