- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.05 / $1,494.05 / $2,334.46
| Facility | | $1,494.05 | $1,494.05 | $2,334.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.70 / $2,142.26 / $2,334.46
| Professional | | $1,357.70 | $2,142.26 | $2,334.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,065.96 / $2,065.96 / $2,065.96
| Facility | | $2,065.96 | $2,065.96 | $2,065.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.96 / $2,065.96 / $2,065.96
| Professional | | $2,065.96 | $2,065.96 | $2,065.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,747.16
| Facility | | $1,747.16 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,275.43 / $1,747.16
| Professional | | $1,275.43 | $1,275.43 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.85 / $1,330.05 / $1,812.70
| Professional | | $751.85 | $1,330.05 | $1,812.70 |