- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.03 / $1,460.03 / $2,281.29
| Facility | | $1,460.03 | $1,460.03 | $2,281.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.58 / $2,190.04 / $2,536.78
| Professional | | $1,428.58 | $2,190.04 | $2,536.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.91 / $2,018.91 / $2,018.91
| Facility | | $2,018.91 | $2,018.91 | $2,018.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.91 / $2,018.91 / $2,018.91
| Professional | | $2,018.91 | $2,018.91 | $2,018.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.28 / $1,486.28 / $1,486.28
| Facility | | $1,486.28 | $1,486.28 | $1,486.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,084.98 / $1,486.28
| Professional | | $1,084.98 | $1,084.98 | $1,486.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.89 / $1,428.89 / $1,428.89
| Facility | | $1,428.89 | $1,428.89 | $1,428.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.10 / $1,299.76 / $2,055.90
| Professional | | $791.10 | $1,299.76 | $2,055.90 |