- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,389.51 / $1,652.14 / $1,652.14
| Facility | | $1,389.51 | $1,652.14 | $1,652.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,336.58 / $1,588.01
| Professional | | $1,323.35 | $1,336.58 | $1,588.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,051.72 / $1,051.72 / $1,156.89
| Facility | | $1,051.72 | $1,051.72 | $1,156.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.08 / $1,066.08 / $1,402.86
| Professional | | $1,066.08 | $1,066.08 | $1,402.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,392.52
| Facility | | $1,323.35 | $1,323.35 | $1,392.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,373.28
| Professional | | $1,323.35 | $1,323.35 | $1,373.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.25 / $1,921.25 / $1,921.25
| Professional | | $1,921.25 | $1,921.25 | $1,921.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.18 / $1,323.35 / $1,799.76
| Professional | | $1,257.18 | $1,323.35 | $1,799.76 |