- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,466.78 / $1,595.74
| Facility | | $1,452.25 | $1,466.78 | $1,595.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,568.43
| Professional | | $1,452.25 | $1,452.25 | $1,568.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $2,802.84
| Facility | | $1,452.25 | $1,452.25 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,597.47
| Professional | | $1,452.25 | $1,452.25 | $1,597.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,452.25 / $1,452.25
| Facility | | $1,370.05 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,507.05
| Professional | | $1,452.25 | $1,452.25 | $1,507.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,548.62
| Facility | | $1,452.25 | $1,452.25 | $1,548.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,670.09
| Professional | | $1,452.25 | $1,452.25 | $1,670.09 |