- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.15 / $1,644.15 / $2,568.98
| Facility | | $1,644.15 | $1,644.15 | $2,568.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.80 / $2,357.15 / $2,568.98
| Professional | | $1,509.80 | $2,357.15 | $2,568.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,273.51 / $2,273.51 / $2,273.51
| Facility | | $2,273.51 | $2,273.51 | $2,273.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.51 / $2,273.51 / $2,273.51
| Professional | | $2,273.51 | $2,273.51 | $2,273.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $2,373.71
| Facility | | $2,373.71 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,017.65 / $2,373.71
| Professional | | $2,017.65 | $2,017.65 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.36 / $1,463.67 / $2,053.41
| Professional | | $888.36 | $1,463.67 | $2,053.41 |