- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,896.24 / $1,896.24 / $2,962.88
| Facility | | $1,896.24 | $1,896.24 | $2,962.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.93 / $2,962.88 / $3,676.27
| Professional | | $1,792.93 | $2,962.88 | $3,676.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,622.10 / $2,622.10 / $2,622.10
| Facility | | $2,622.10 | $2,622.10 | $2,622.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.10 / $2,622.10 / $2,622.10
| Professional | | $2,622.10 | $2,622.10 | $2,622.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,375.33 / $2,375.33 / $2,375.33
| Facility | | $2,375.33 | $2,375.33 | $2,375.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.99 / $1,733.99 / $2,375.33
| Professional | | $1,733.99 | $1,733.99 | $2,375.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,834.85 / $4,511.59 / $5,413.91
| Facility | | $3,834.85 | $4,511.59 | $5,413.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.39 / $1,688.09 / $2,601.29
| Professional | | $1,125.39 | $1,688.09 | $2,601.29 |