- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,532.67 / $1,532.67 / $1,532.67
| Facility | | $1,532.67 | $1,532.67 | $1,532.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.49 / $1,425.31 / $1,532.67
| Professional | | $1,266.49 | $1,425.31 | $1,532.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,443.91 / $3,153.43 / $3,607.84
| Facility | | $2,443.91 | $3,153.43 | $3,607.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.28 / $1,624.28 / $1,704.50
| Professional | | $1,624.28 | $1,624.28 | $1,704.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $2,373.71
| Facility | | $2,373.71 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,017.65 / $2,373.71
| Professional | | $2,017.65 | $2,017.65 | $2,373.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,049.73 / $2,049.73 / $2,049.73
| Facility | | $2,049.73 | $2,049.73 | $2,049.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.73 / $2,128.91 / $3,013.22
| Professional | | $2,049.73 | $2,128.91 | $3,013.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.58 / $1,573.21 / $2,053.41
| Professional | | $1,200.58 | $1,573.21 | $2,053.41 |