- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $3,630.78
| Facility | | $1,318.26 | $2,187.76 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,318.26 / $1,778.28
| Professional | | $1,288.25 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $3,630.78
| Facility | | $1,412.54 | $1,778.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,778.28
| Professional | | $1,318.26 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $2,187.76
| Facility | | $1,230.27 | $1,318.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,659.59
| Professional | | $1,318.26 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,570.40
| Facility | | $1,318.26 | $1,318.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,380.38 / $1,584.89
| Professional | | $1,318.26 | $1,380.38 | $1,584.89 |