- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $4,265.80
| Facility | | $1,778.28 | $1,778.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $1,949.84
| Professional | | $1,258.93 | $1,778.28 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,949.84
| Facility | | $1,905.46 | $1,905.46 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $1,949.84
| Professional | | $1,445.44 | $1,905.46 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,238.72
| Professional | | $1,778.28 | $1,778.28 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $2,951.21
| Facility | | $1,513.56 | $1,548.82 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $2,089.30
| Professional | | $1,737.80 | $1,949.84 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,949.84 / $2,187.76
| Professional | | $1,778.28 | $1,949.84 | $2,187.76 |