- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,290.87
| Facility | | $1,778.28 | $1,778.28 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,819.70 / $1,862.09
| Professional | | $1,778.28 | $1,819.70 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.34 / $2.34 / $2,041.74
| Professional | | $2.34 | $2.34 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,715.35 / $3,715.35
| Professional | | $2,089.30 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- 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
- $1,778.28 / $2,187.76 / $4,897.79
| Facility | | $1,778.28 | $2,187.76 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $8,317.64
| Professional | | $2,089.30 | $2,187.76 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,715.35
| Facility | | $3,467.37 | $3,467.37 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $2,344.23
| Professional | | $1,995.26 | $2,187.76 | $2,344.23 |