- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.52 / $1,482.52 / $2,001.73
| Facility | | $1,482.52 | $1,482.52 | $2,001.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.99 / $1,492.48 / $2,088.88
| Professional | | $1,140.99 | $1,492.48 | $2,088.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,484.96 / $3,339.82 / $5,525.88
| Facility | | $2,484.96 | $3,339.82 | $5,525.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.14 / $1,518.14 / $2,582.77
| Professional | | $1,518.14 | $1,518.14 | $2,582.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.76 / $1,552.76 / $1,572.18
| Facility | | $1,552.76 | $1,552.76 | $1,572.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $3,378.95
| Professional | | $1,133.51 | $1,133.51 | $3,378.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.98 / $1,436.82 / $2,028.70
| Professional | | $1,101.98 | $1,436.82 | $2,028.70 |