- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,600.51 / $1,600.51 / $2,500.79
| Facility | | $1,600.51 | $1,600.51 | $2,500.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.40 / $2,423.54 / $2,500.79
| Professional | | $1,502.40 | $2,423.54 | $2,500.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.16 / $2,213.16 / $2,213.16
| Facility | | $2,213.16 | $2,213.16 | $2,213.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.16 / $2,213.16 / $2,213.16
| Professional | | $2,213.16 | $2,213.16 | $2,213.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,050.41
| Facility | | $2,050.41 | $2,050.41 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $2,718.36
| Professional | | $1,496.80 | $1,496.80 | $2,718.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,424.81 / $2,195.59
| Professional | | $949.88 | $1,424.81 | $2,195.59 |