- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.65 / $2,170.37 / $3,997.84
| Facility | | $1,808.65 | $2,170.37 | $3,997.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,826.73 / $2,193.05
| Professional | | $1,808.65 | $1,826.73 | $2,193.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.64 / $2,908.02 / $5,750.58
| Facility | | $1,808.64 | $2,908.02 | $5,750.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $2,002.81
| Professional | | $1,808.65 | $1,808.65 | $2,002.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,706.27 / $1,808.65 / $1,808.65
| Facility | | $1,706.27 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,808.65
| Professional | | $1,808.65 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.65 / $1,520.65 / $1,855.00
| Facility | | $1,520.65 | $1,520.65 | $1,855.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $2,046.13
| Professional | | $1,808.65 | $1,808.65 | $2,046.13 |