- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,625.21 / $1,625.21 / $1,716.65
| Facility | | $1,625.21 | $1,625.21 | $1,716.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.43 / $1,479.37 / $1,909.88
| Professional | | $1,144.43 | $1,479.37 | $1,909.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.12 / $2,329.34 / $2,329.34
| Facility | | $2,089.12 | $2,329.34 | $2,329.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.58 / $1,924.11 / $1,957.21
| Professional | | $1,273.58 | $1,924.11 | $1,957.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $3,408.75
| Professional | | $1,232.84 | $1,232.84 | $3,408.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.96 / $1,100.01 / $1,741.68
| Professional | | $853.96 | $1,100.01 | $1,741.68 |