- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.10 / $1,606.10 / $1,696.46
| Facility | | $1,606.10 | $1,606.10 | $1,696.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.60 / $1,534.77 / $2,040.00
| Professional | | $1,071.60 | $1,534.77 | $2,040.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.26 / $2,583.10 / $3,006.97
| Facility | | $2,510.26 | $2,583.10 | $3,006.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.80 / $1,901.61 / $1,962.69
| Professional | | $1,556.80 | $1,901.61 | $1,962.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $2,398.78
| Professional | | $1,241.43 | $1,460.50 | $2,398.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.12 / $1,248.47 / $1,825.63
| Professional | | $859.12 | $1,248.47 | $1,825.63 |