- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.19 / $1,875.82 / $2,149.12
| Facility | | $1,744.19 | $1,875.82 | $2,149.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.19 / $2,091.67 / $3,040.70
| Professional | | $1,744.19 | $2,091.67 | $3,040.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $2,282.71
| Facility | | $2,282.71 | $2,282.71 | $2,282.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $2,282.71
| Professional | | $1,666.39 | $1,666.39 | $2,282.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,415.12 / $2,719.58 / $2,719.58
| Facility | | $1,415.12 | $2,719.58 | $2,719.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.16 / $2,719.58 / $4,085.36
| Professional | | $1,947.16 | $2,719.58 | $4,085.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,268.28 / $3,268.28 / $3,268.28
| Professional | | $3,268.28 | $3,268.28 | $3,268.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.38 / $2,038.15 / $2,746.00
| Professional | | $1,754.38 | $2,038.15 | $2,746.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.84 / $2,207.84 / $4,085.36
| Professional | | $2,207.84 | $2,207.84 | $4,085.36 |