- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.65 / $3,600.79 / $4,584.04
| Facility | | $1,808.65 | $3,600.79 | $4,584.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,918.01 / $2,189.42
| Professional | | $1,808.65 | $1,918.01 | $2,189.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,989.50 / $3,175.63 / $5,787.68
| Facility | | $1,989.50 | $3,175.63 | $5,787.68 |
- 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
- $1,706.27 / $1,706.27 / $2,559.40
| Facility | | $1,706.27 | $1,706.27 | $2,559.40 |
- 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
- $1,251.97 / $1,917.16 / $3,000.18
| Facility | | $1,251.97 | $1,917.16 | $3,000.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.49 / $1,989.51 / $2,966.19
| Professional | | $1,356.49 | $1,989.51 | $2,966.19 |
- 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 |