- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.31 / $1,537.31 / $7,961.54
| Facility | | $1,537.31 | $1,537.31 | $7,961.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,844.82 / $2,532.10
| Professional | | $1,808.65 | $1,844.82 | $2,532.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.41 / $2,113.69 / $2,224.94
| Facility | | $1,648.41 | $2,113.69 | $2,224.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.65 / $1,876.65 / $1,876.65
| Professional | | $1,876.65 | $1,876.65 | $1,876.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,706.27 / $1,706.27 / $1,808.65
| Facility | | $1,706.27 | $1,706.27 | $1,808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,808.65
| Professional | | $1,808.65 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.43 / $1,809.44 / $2,533.21
| Facility | | $1,124.43 | $1,809.44 | $2,533.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.44 / $1,809.44 / $2,029.45
| Professional | | $1,809.44 | $1,809.44 | $2,029.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $2,108.21
| Professional | | $1,808.65 | $1,808.65 | $2,108.21 |