- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,344.23
| Facility | | $1,698.24 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,698.24
| Professional | | $794.33 | $1,122.02 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,819.70
| Professional | | $1,348.96 | $1,348.96 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,737.80 / $2,511.89
| Facility | | $870.96 | $1,737.80 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,348.96
| Facility | | $1,202.26 | $1,202.26 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,348.96
| Professional | | $562.34 | $794.33 | $1,348.96 |