- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,607.00 / $1,728.28 / $1,980.08
| Facility | | $1,607.00 | $1,728.28 | $1,980.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.00 / $1,927.12 / $2,801.54
| Professional | | $1,607.00 | $1,927.12 | $2,801.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,264.80
| Facility | | $2,264.80 | $2,264.80 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $1,653.30 / $2,369.73
| Professional | | $1,653.30 | $1,653.30 | $2,369.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,505.67 / $2,505.67 / $2,505.67
| Facility | | $2,505.67 | $2,505.67 | $2,505.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.01 / $2,515.01 / $3,764.05
| Professional | | $2,012.01 | $2,515.01 | $3,764.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.47 / $2,503.80 / $2,754.18
| Professional | | $1,627.47 | $2,503.80 | $2,754.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.39 / $1,877.84 / $2,513.88
| Professional | | $1,616.39 | $1,877.84 | $2,513.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,503.80 / $2,503.80 / $2,503.80
| Professional | | $2,503.80 | $2,503.80 | $2,503.80 |