- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,348.96
| Facility | | $1,122.02 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $1,778.28
| Professional | | $831.76 | $1,071.52 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,187.76 / $2,511.89
| Facility | | $2,041.74 | $2,187.76 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Professional | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,348.96
| Professional | | $977.24 | $977.24 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $3,090.30
| Professional | | $1,778.28 | $1,778.28 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $912.01 / $1,202.26
| Facility | | $562.34 | $912.01 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,778.28
| Professional | | $691.83 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,884.03
| Facility | | $1,819.70 | $1,819.70 | $2,884.03 |