- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,729.03 / $1,729.03 / $2,701.61
| Facility | | $1,729.03 | $1,729.03 | $2,701.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.80 / $2,478.76 / $3,296.24
| Professional | | $1,690.80 | $2,478.76 | $3,296.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,390.88 / $2,390.88 / $2,390.88
| Facility | | $2,390.88 | $2,390.88 | $2,390.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.88 / $2,390.88 / $2,390.88
| Professional | | $2,390.88 | $2,390.88 | $2,390.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $2,253.75
| Facility | | $2,253.75 | $2,253.75 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $1,915.69 / $2,253.75
| Professional | | $1,915.69 | $1,915.69 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.65 / $1,539.23 / $2,269.04
| Professional | | $981.65 | $1,539.23 | $2,269.04 |