- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $6,309.57
| Facility | | $1,819.70 | $3,311.31 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,862.09 / $2,951.21
| Professional | | $1,819.70 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $5,128.61
| Facility | | $1,905.46 | $2,511.89 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,754.23
| Professional | | $1,819.70 | $1,819.70 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $3,235.94
| Facility | | $1,737.80 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,862.09 / $2,344.23
| Professional | | $1,819.70 | $1,862.09 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $3,235.94
| Facility | | $1,737.80 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,630.27
| Professional | | $1,819.70 | $1,819.70 | $2,630.27 |