- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,819.70 / $2,187.76
| Facility | | $1,778.28 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,819.70 / $1,905.46
| Professional | | $1,778.28 | $1,819.70 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $6,309.57
| Facility | | $1,995.26 | $2,511.89 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.69 / $1,995.26 / $2,454.71
| Professional | | $2.69 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,238.72
| Facility | | $1,862.09 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,467.37 / $7,943.28
| Facility | | $2,290.87 | $3,467.37 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,290.87
| Professional | | $2,187.76 | $2,187.76 | $2,290.87 |