- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.73 / $1,436.73 / $3,018.93
| Facility | | $1,436.73 | $1,436.73 | $3,018.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.73 / $1,474.09 / $1,502.29
| Professional | | $1,436.73 | $1,474.09 | $1,502.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,384.94 / $2,701.94 / $3,018.93
| Facility | | $2,384.94 | $2,701.94 | $3,018.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.49 / $1,647.60 / $2,273.67
| Professional | | $1,512.49 | $1,647.60 | $2,273.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,276.44 / $3,320.82 / $4,528.39
| Facility | | $2,276.44 | $3,320.82 | $4,528.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,566.09 / $3,320.82 / $4,075.56
| Professional | | $2,566.09 | $3,320.82 | $4,075.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $3,018.93
| Facility | | $1,952.91 | $1,952.91 | $3,018.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,952.91 / $3,096.84
| Professional | | $1,425.62 | $1,952.91 | $3,096.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.96 / $1,506.11 / $2,073.29
| Professional | | $896.96 | $1,506.11 | $2,073.29 |