- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.13 / $1,975.01 / $3,417.03
| Facility | | $1,861.13 | $1,975.01 | $3,417.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.01 / $1,975.01 / $1,975.01
| Professional | | $1,975.01 | $1,975.01 | $1,975.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.30 / $4,128.58 / $6,486.89
| Facility | | $2,658.30 | $4,128.58 | $6,486.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,725.20 / $1,828.71
| Facility | | $1,725.20 | $1,725.20 | $1,828.71 |
- 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
- $1,861.13 / $2,651.64 / $6,490.42
| Facility | | $1,861.13 | $2,651.64 | $6,490.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.81 / $1,861.13 / $1,861.13
| Professional | | $1,755.81 | $1,861.13 | $1,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,828.72
| Professional | | $1,828.72 | $1,828.72 | $1,828.72 |