- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,698.24
| Facility | | $1,513.56 | $1,513.56 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,698.24
| Professional | | $1,412.54 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,318.26 / $1,479.11
| Professional | | $125.89 | $1,318.26 | $1,479.11 |