- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.65 / $2,714.16 / $4,125.52
| Facility | | $1,808.65 | $2,714.16 | $4,125.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,989.51
| Professional | | $1,808.65 | $1,808.65 | $1,989.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,706.27 / $1,808.65 / $1,904.82
| Facility | | $1,706.27 | $1,808.65 | $1,904.82 |
- 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
- $793.51 / $1,808.65 / $1,808.65
| Facility | | $793.51 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.64 / $1,842.77 / $1,842.77
| Professional | | $1,808.64 | $1,842.77 | $1,842.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $2,025.69
| Professional | | $1,808.65 | $1,808.65 | $2,025.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,809.44
| Professional | | $1,808.65 | $1,808.65 | $1,809.44 |