- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,539.24 / $1,542.24
| Facility | | $1,494.41 | $1,539.24 | $1,542.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,603.93
| Professional | | $1,494.41 | $1,494.41 | $1,603.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $2,884.21
| Facility | | $1,494.41 | $1,494.41 | $2,884.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,565.85
| Professional | | $1,494.41 | $1,494.41 | $1,565.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.82 / $1,494.41 / $1,494.41
| Facility | | $1,409.82 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,705.81
| Professional | | $1,494.41 | $1,494.41 | $1,705.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,483.05 / $4,483.05 / $4,483.05
| Facility | | $4,483.05 | $4,483.05 | $4,483.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,793.29
| Professional | | $1,494.41 | $1,494.41 | $1,793.29 |