- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.50 / $1,530.50 / $1,530.50
| Facility | | $1,530.50 | $1,530.50 | $1,530.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.17 / $2,554.17 / $2,554.17
| Professional | | $2,554.17 | $2,554.17 | $2,554.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.83 / $2,168.86 / $3,018.28
| Facility | | $1,239.83 | $2,168.86 | $3,018.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.26 / $1,526.92 / $1,946.88
| Professional | | $1,357.26 | $1,526.92 | $1,946.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,141.71 / $3,212.58 / $4,250.93
| Facility | | $2,141.71 | $3,212.58 | $4,250.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,401.83 / $2,031.22 / $3,561.80
| Facility | | $1,401.83 | $2,031.22 | $3,561.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.62 / $1,153.64 / $1,891.99
| Professional | | $774.62 | $1,153.64 | $1,891.99 |