- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,596.49 / $1,596.49 / $2,494.52
| Facility | | $1,596.49 | $1,596.49 | $2,494.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.01 / $2,177.36 / $2,538.80
| Professional | | $1,480.01 | $2,177.36 | $2,538.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,207.59 / $2,207.59 / $2,207.59
| Facility | | $2,207.59 | $2,207.59 | $2,207.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.59 / $2,207.59 / $2,207.59
| Professional | | $2,207.59 | $2,207.59 | $2,207.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.76 / $1,960.76 / $1,960.76
| Facility | | $1,960.76 | $1,960.76 | $1,960.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,431.35 / $1,960.76
| Professional | | $1,431.35 | $1,431.35 | $1,960.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.07 / $1,421.24 / $2,248.01
| Professional | | $817.07 | $1,421.24 | $2,248.01 |