- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,611.24 / $1,611.24 / $1,611.24
| Facility | | $1,611.24 | $1,611.24 | $1,611.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.45 / $1,717.66 / $1,940.57
| Professional | | $1,448.45 | $1,717.66 | $1,940.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.19 / $3,315.08 / $3,792.78
| Facility | | $2,569.19 | $3,315.08 | $3,792.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.27 / $2,025.27 / $2,115.48
| Professional | | $2,025.27 | $2,025.27 | $2,115.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $2,637.76
| Facility | | $2,637.76 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $1,925.56 / $2,637.76
| Professional | | $1,925.56 | $1,925.56 | $2,637.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,154.80 / $2,154.80 / $2,154.80
| Facility | | $2,154.80 | $2,154.80 | $2,154.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.80 / $2,386.86 / $3,315.08
| Professional | | $2,154.80 | $2,386.86 | $3,315.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.17 / $2,106.17 / $2,106.17
| Professional | | $2,106.17 | $2,106.17 | $2,106.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.14 / $1,653.86 / $2,524.27
| Professional | | $1,262.14 | $1,653.86 | $2,524.27 |