- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $5,248.07
| Facility | | $1,819.70 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,511.89
| Professional | | $1,819.70 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $5,011.87
| Facility | | $1,905.46 | $2,454.71 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,454.71
| Professional | | $1,819.70 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $2,754.23
| Facility | | $1,698.24 | $1,819.70 | $2,754.23 |
- 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
- $1,819.70 / $1,819.70 / $3,162.28
| Facility | | $1,819.70 | $1,819.70 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,187.76
| Professional | | $1,819.70 | $1,819.70 | $2,187.76 |