- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,809.44 / $2,026.57 / $3,618.88
| Facility | | $1,809.44 | $2,026.57 | $3,618.88 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.73 / $3,255.57 / $8,204.70
| Facility | | $2,155.73 | $3,255.57 | $8,204.70 |
- 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 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,897.64 / $2,937.25 / $5,582.40
| Professional | | $1,897.64 | $2,937.25 | $5,582.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $2,025.69 / $2,025.69
| Professional | | $1,808.65 | $2,025.69 | $2,025.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.53 / $1,810.08 / $2,303.73
| Professional | | $1,645.53 | $1,810.08 | $2,303.73 |