- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.05 / $1,407.05 / $1,730.31
| Facility | | $1,407.05 | $1,407.05 | $1,730.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,532.43
| Professional | | $1,393.12 | $1,393.12 | $1,532.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $2,688.72
| Facility | | $1,393.12 | $1,393.12 | $2,688.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,978.23
| Professional | | $1,393.12 | $1,393.12 | $1,978.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $2,089.67
| Facility | | $1,393.12 | $1,393.12 | $2,089.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,671.74
| Professional | | $1,393.12 | $1,393.12 | $1,671.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,393.12
| Facility | | $1,393.12 | $1,393.12 | $1,393.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,393.12
| Professional | | $1,393.12 | $1,393.12 | $1,393.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,860.93
| Professional | | $1,393.12 | $1,393.12 | $1,860.93 |