- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,498.82 / $1,498.82 / $1,712.94
| Facility | | $1,498.82 | $1,498.82 | $1,712.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,498.82 / $1,712.94
| Professional | | $1,427.45 | $1,498.82 | $1,712.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Facility | | $1,427.45 | $1,427.45 | $1,427.45 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,313.25 / $1,427.45 / $1,855.69
| Professional | | $1,313.25 | $1,427.45 | $1,855.69 |