- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,883.58 / $1,916.97 / $5,980.95
| Facility | | $1,883.58 | $1,916.97 | $5,980.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,883.58 / $2,251.96
| Professional | | $1,828.72 | $1,883.58 | $2,251.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,260.63 / $4,072.42 / $7,703.81
| Facility | | $2,260.63 | $4,072.42 | $7,703.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.05 / $1,863.21 / $1,863.21
| Professional | | $1,770.05 | $1,863.21 | $1,863.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $3,409.15
| Professional | | $1,828.71 | $1,828.71 | $3,409.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.72 / $3,354.70 / $5,333.97
| Facility | | $1,828.72 | $3,354.70 | $5,333.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,883.58 / $2,194.46
| Professional | | $1,828.72 | $1,883.58 | $2,194.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,019.18 / $2,103.02 / $2,140.29
| Professional | | $2,019.18 | $2,103.02 | $2,140.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,940.09
| Professional | | $1,828.72 | $1,828.72 | $1,940.09 |