- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,441.72
| Facility | | $1,427.45 | $1,427.45 | $1,441.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,498.82
| Professional | | $1,427.45 | $1,427.45 | $1,498.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,427.45 / $2,691.15
| Facility | | $1,375.24 | $1,427.45 | $2,691.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.65 / $1,427.45 / $1,427.45
| Facility | | $1,346.65 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,481.32
| Professional | | $1,427.45 | $1,427.45 | $1,481.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,692.25 / $2,288.69 / $2,288.69
| Facility | | $1,692.25 | $2,288.69 | $2,288.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,627.29
| Professional | | $1,427.45 | $1,427.45 | $1,627.29 |