- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.31 / $2,335.92 / $5,867.68
| Facility | | $1,730.31 | $2,335.92 | $5,867.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.31 / $1,747.63 / $1,922.39
| Professional | | $1,730.31 | $1,747.63 | $1,922.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.22 / $1,133.72 / $1,525.21
| Facility | | $934.22 | $1,133.72 | $1,525.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,791.74
| Professional | | $1,730.32 | $1,730.32 | $1,791.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Facility | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,894.78
| Professional | | $1,730.32 | $1,730.32 | $1,894.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.52 / $1,770.52 / $1,770.52
| Facility | | $1,770.52 | $1,770.52 | $1,770.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,834.14
| Professional | | $1,730.32 | $1,730.32 | $1,834.14 |