- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,715.42 / $1,899.77 / $2,050.54
| Facility | | $1,715.42 | $1,899.77 | $2,050.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.17 / $1,863.70 / $2,378.50
| Professional | | $1,437.17 | $1,863.70 | $2,378.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.20 / $1,505.20 / $2,905.04
| Facility | | $1,505.20 | $1,505.20 | $2,905.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.19 / $1,570.63 / $2,220.10
| Professional | | $1,505.19 | $1,570.63 | $2,220.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Facility | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.27 / $1,950.00 / $3,224.93
| Professional | | $268.27 | $1,950.00 | $3,224.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.35 / $1,344.18 / $2,340.76
| Professional | | $1,014.35 | $1,344.18 | $2,340.76 |