- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.53 / $1,294.53 / $2,022.71
| Facility | | $1,294.53 | $1,294.53 | $2,022.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.53 / $2,022.71 / $2,543.56
| Professional | | $1,294.53 | $2,022.71 | $2,543.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,790.07 / $1,790.07 / $1,790.07
| Facility | | $1,790.07 | $1,790.07 | $1,790.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.07 / $1,790.07 / $1,790.07
| Professional | | $1,790.07 | $1,790.07 | $1,790.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,964.43 / $1,964.43 / $1,964.43
| Facility | | $1,964.43 | $1,964.43 | $1,964.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.03 / $1,434.03 / $1,964.43
| Professional | | $1,434.03 | $1,434.03 | $1,964.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.29 / $1,152.43 / $1,822.84
| Professional | | $768.29 | $1,152.43 | $1,822.84 |