- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.62 / $1,618.62 / $2,529.09
| Facility | | $1,618.62 | $1,618.62 | $2,529.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.25 / $2,456.50 / $2,780.15
| Professional | | $1,608.25 | $2,456.50 | $2,780.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.21 / $2,238.21 / $2,238.21
| Facility | | $2,238.21 | $2,238.21 | $2,238.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.21 / $2,238.21 / $2,238.21
| Professional | | $2,238.21 | $2,238.21 | $2,238.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $1,743.07
| Facility | | $1,743.07 | $1,743.07 | $1,743.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $2,749.12
| Professional | | $1,272.44 | $1,272.44 | $2,749.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.78 / $1,440.94 / $2,144.53
| Professional | | $927.78 | $1,440.94 | $2,144.53 |