- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.87 / $1,862.87 / $1,862.87
| Facility | | $1,862.87 | $1,862.87 | $1,862.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.96 / $1,728.44 / $1,866.72
| Professional | | $1,667.96 | $1,728.44 | $1,866.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.42 / $3,832.80 / $4,385.10
| Facility | | $2,970.42 | $3,832.80 | $4,385.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.16 / $2,143.16 / $2,238.63
| Professional | | $2,143.16 | $2,143.16 | $2,238.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $2,540.30
| Facility | | $2,540.30 | $2,540.30 | $2,540.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $1,854.42 / $2,540.30
| Professional | | $1,854.42 | $1,854.42 | $2,540.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,491.32 / $2,491.32 / $2,491.32
| Facility | | $2,491.32 | $2,491.32 | $2,491.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,491.32 / $2,491.32 / $3,526.18
| Professional | | $2,491.32 | $2,491.32 | $3,526.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,798.10 / $2,798.10 / $2,798.10
| Professional | | $2,798.10 | $2,798.10 | $2,798.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.25 / $1,912.15 / $2,678.16
| Professional | | $1,459.25 | $1,912.15 | $2,678.16 |