- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,339.48 / $2,387.26 / $2,519.44
| Facility | | $2,339.48 | $2,387.26 | $2,519.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.06 / $2,354.80 / $3,097.44
| Professional | | $1,841.06 | $2,354.80 | $3,097.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,751.98 / $3,381.32
| Facility | | $1,751.98 | $1,751.98 | $3,381.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,923.79 / $4,362.59
| Professional | | $1,751.98 | $1,923.79 | $4,362.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,195.38 / $3,360.51 / $3,360.51
| Facility | | $2,195.38 | $3,360.51 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.88 / $1,472.88 / $3,637.50
| Professional | | $1,472.88 | $1,472.88 | $3,637.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.57 / $365.23 / $2,920.70
| Professional | | $151.57 | $365.23 | $2,920.70 |