- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $9,772.37
| Facility | | $1,778.28 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,819.70 / $7,413.10
| Professional | | $1,778.28 | $1,819.70 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $5,370.32
| Facility | | $1,819.70 | $2,398.83 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,778.28 / $2,344.23
| Professional | | $1,737.80 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $2,511.89
| Facility | | $1,659.59 | $1,778.28 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,819.70 / $2,290.87
| Professional | | $1,778.28 | $1,819.70 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $2,951.21
| Facility | | $1,659.59 | $1,778.28 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,862.09 / $2,238.72
| Professional | | $1,778.28 | $1,862.09 | $2,238.72 |