- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.67 / $1,654.67 / $1,654.67
| Facility | | $1,654.67 | $1,654.67 | $1,654.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.18 / $1,654.67 / $1,751.71
| Professional | | $1,409.18 | $1,654.67 | $1,751.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.82 / $2,361.91 / $2,639.01
| Facility | | $2,084.82 | $2,361.91 | $2,639.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.91 / $2,024.42 / $2,672.23
| Professional | | $1,458.91 | $2,024.42 | $2,672.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.32 / $1,847.31 / $3,430.71
| Facility | | $224.32 | $1,847.31 | $3,430.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.32 / $1,715.36 / $3,166.81
| Professional | | $224.32 | $1,715.36 | $3,166.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Facility | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.99 / $2,217.64 / $2,736.17
| Professional | | $1,884.99 | $2,217.64 | $2,736.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.71 / $1,324.07 / $2,017.09
| Professional | | $882.71 | $1,324.07 | $2,017.09 |