- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.62 / $1,657.62 / $1,994.42
| Facility | | $1,615.62 | $1,657.62 | $1,994.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.68 / $1,680.24 / $2,353.13
| Professional | | $1,289.68 | $1,680.24 | $2,353.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,831.32 / $3,401.26 / $6,223.96
| Facility | | $2,831.32 | $3,401.26 | $6,223.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.80 / $1,806.78 / $2,531.84
| Professional | | $1,700.80 | $1,806.78 | $2,531.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.18 / $1,769.18 / $1,769.18
| Facility | | $1,769.18 | $1,769.18 | $1,769.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.50 / $1,769.17 / $1,997.68
| Professional | | $1,291.50 | $1,769.17 | $1,997.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.09 / $1,552.53 / $2,238.84
| Professional | | $1,177.09 | $1,552.53 | $2,238.84 |