- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $3,137.87 / $6,053.06
| Facility | | $1,828.72 | $3,137.87 | $6,053.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $2,011.59
| Professional | | $1,828.72 | $1,828.72 | $2,011.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,828.71 / $1,868.62
| Facility | | $1,725.20 | $1,828.71 | $1,868.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Professional | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,828.72
| Facility | | $1,828.72 | $1,828.72 | $1,828.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,932.23 / $1,932.23
| Professional | | $1,828.72 | $1,932.23 | $1,932.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $2,743.08
| Professional | | $1,828.72 | $1,828.72 | $2,743.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,861.13
| Professional | | $1,828.72 | $1,828.72 | $1,861.13 |