- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.87 / $1,605.87 / $1,605.87
| Facility | | $1,605.87 | $1,605.87 | $1,605.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.39 / $1,492.25 / $1,607.06
| Professional | | $1,336.39 | $1,492.25 | $1,607.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,560.63 / $3,304.04 / $3,780.15
| Facility | | $2,560.63 | $3,304.04 | $3,780.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.10 / $1,876.10 / $1,959.67
| Professional | | $1,876.10 | $1,876.10 | $1,959.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,571.77 / $2,571.77
| Facility | | $2,571.77 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $1,877.39 / $2,571.77
| Professional | | $1,877.39 | $1,877.39 | $2,571.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.63 / $2,147.63 / $2,147.63
| Facility | | $2,147.63 | $2,147.63 | $2,147.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.09 / $2,147.63 / $2,825.23
| Professional | | $1,996.09 | $2,147.63 | $2,825.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.75 / $2,213.75 / $2,213.75
| Professional | | $2,213.75 | $2,213.75 | $2,213.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.93 / $1,648.35 / $2,360.82
| Professional | | $1,257.93 | $1,648.35 | $2,360.82 |