- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.32 / $3,277.89 / $8,167.41
| Facility | | $1,730.32 | $3,277.89 | $8,167.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.31 / $1,764.93 / $2,386.08
| Professional | | $1,730.31 | $1,764.93 | $2,386.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.32 / $2,785.82 / $5,483.38
| Facility | | $1,730.32 | $2,785.82 | $5,483.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,737.10
| Professional | | $1,730.32 | $1,730.32 | $1,737.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.38 / $1,730.32 / $1,730.32
| Facility | | $1,632.38 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,670.30 / $1,737.10 / $2,037.77
| Facility | | $1,670.30 | $1,737.10 | $2,037.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,834.14 / $2,118.83
| Professional | | $1,730.32 | $1,834.14 | $2,118.83 |