- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.76 / $1,560.76 / $2,438.67
| Facility | | $1,560.76 | $1,560.76 | $2,438.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.76 / $2,438.67 / $2,751.49
| Professional | | $1,560.76 | $2,438.67 | $2,751.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,158.19 / $2,158.19 / $2,158.19
| Facility | | $2,158.19 | $2,158.19 | $2,158.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.19 / $2,158.19 / $2,158.19
| Professional | | $2,158.19 | $2,158.19 | $2,158.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.02 / $2,125.02 / $2,125.02
| Facility | | $2,125.02 | $2,125.02 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $1,551.26 / $2,125.02
| Professional | | $1,551.26 | $1,551.26 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.28 / $1,389.43 / $2,141.06
| Professional | | $926.28 | $1,389.43 | $2,141.06 |