- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,898.36 / $3,837.60 / $8,188.97
| Facility | | $1,898.36 | $3,837.60 | $8,188.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,975.01 / $3,837.60
| Professional | | $1,828.72 | $1,975.01 | $3,837.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,314.35 / $2,436.16 / $3,892.67
| Facility | | $2,314.35 | $2,436.16 | $3,892.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.41 / $1,924.41 / $1,924.41
| Professional | | $1,924.41 | $1,924.41 | $1,924.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,725.20 / $1,828.71
| Facility | | $1,725.20 | $1,725.20 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Professional | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.13 / $2,605.59 / $3,837.60
| Facility | | $1,861.13 | $2,605.59 | $3,837.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.81 / $1,861.13 / $2,977.81
| Professional | | $1,755.81 | $1,861.13 | $2,977.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $3,108.82
| Professional | | $1,828.72 | $1,828.72 | $3,108.82 |