- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,874.68 / $1,874.68 / $2,249.62
| Facility | | $1,874.68 | $1,874.68 | $2,249.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.71 / $1,572.25 / $1,874.68
| Professional | | $1,454.71 | $1,572.25 | $1,874.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,329.42 / $3,329.42 / $3,946.69
| Facility | | $3,329.42 | $3,329.42 | $3,946.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.67 / $1,790.67 / $1,883.48
| Professional | | $1,790.67 | $1,790.67 | $1,883.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $2,253.75
| Facility | | $2,253.75 | $2,253.75 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $1,915.69 / $2,321.36
| Professional | | $1,915.69 | $1,915.69 | $2,321.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.68 / $2,695.68 / $8,320.21
| Professional | | $2,695.68 | $2,695.68 | $8,320.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.33 / $1,661.01 / $2,218.08
| Professional | | $1,107.33 | $1,661.01 | $2,218.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.92 / $2,414.42 / $3,072.90
| Professional | | $2,194.92 | $2,414.42 | $3,072.90 |