- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.35 / $1,285.35 / $2,700.85
| Facility | | $1,285.35 | $1,285.35 | $2,700.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.01 / $1,311.06 / $1,336.77
| Professional | | $1,155.01 | $1,311.06 | $1,336.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.67 / $2,417.26 / $2,700.85
| Facility | | $2,133.67 | $2,417.26 | $2,700.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.14 / $1,381.04 / $1,905.83
| Professional | | $1,353.14 | $1,381.04 | $1,905.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.64 / $2,970.94 / $3,999.03
| Facility | | $2,025.64 | $2,970.94 | $3,999.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,295.71 / $2,970.94 / $3,646.15
| Professional | | $2,295.71 | $2,970.94 | $3,646.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $2,700.85
| Facility | | $1,747.16 | $1,747.16 | $2,700.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $2,536.44
| Professional | | $1,275.43 | $1,747.16 | $2,536.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.85 / $1,347.43 / $1,788.64
| Professional | | $751.85 | $1,347.43 | $1,788.64 |