- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,829.37 / $1,829.37 / $1,829.37
| Facility | | $1,829.37 | $1,829.37 | $1,829.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.97 / $1,799.19 / $1,908.67
| Professional | | $1,637.97 | $1,799.19 | $1,908.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,917.04 / $3,763.92 / $4,306.30
| Facility | | $2,917.04 | $3,763.92 | $4,306.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.37 / $2,048.37 / $2,198.38
| Professional | | $2,048.37 | $2,048.37 | $2,198.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,326.75
| Facility | | $2,326.75 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $1,698.53 / $2,326.75
| Professional | | $1,698.53 | $1,698.53 | $2,326.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.55 / $2,446.55 / $2,446.55
| Facility | | $2,446.55 | $2,446.55 | $2,446.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,446.55 / $2,446.55 / $3,462.81
| Professional | | $2,446.55 | $2,446.55 | $3,462.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.55 / $2,288.55 / $2,288.55
| Professional | | $2,288.55 | $2,288.55 | $2,288.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.02 / $1,877.77 / $3,129.62
| Professional | | $1,433.02 | $1,877.77 | $3,129.62 |