- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.31 / $3,474.20 / $9,669.53
| Facility | | $1,730.31 | $3,474.20 | $9,669.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.31 / $1,747.63 / $2,376.23
| Professional | | $1,730.31 | $1,747.63 | $2,376.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,903.35 / $3,038.10 / $5,537.02
| Facility | | $1,903.35 | $3,038.10 | $5,537.02 |
- 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
- $1,632.38 / $1,632.38 / $2,368.77
| Facility | | $1,632.38 | $1,632.38 | $2,368.77 |
- 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
- $635.84 / $1,834.14 / $2,870.27
| Facility | | $635.84 | $1,834.14 | $2,870.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.74 / $1,903.36 / $2,837.72
| Professional | | $1,297.74 | $1,903.36 | $2,837.72 |
- 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 |