- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,220.57
| Facility | | $2,068.46 | $2,068.46 | $2,220.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,275.32
| Professional | | $2,068.46 | $2,068.46 | $2,275.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,990.46 / $2,341.71 / $2,341.71
| Facility | | $1,990.46 | $2,341.71 | $2,341.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.63 / $2,341.71 / $2,513.90
| Professional | | $2,224.63 | $2,341.71 | $2,513.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Facility | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.71 / $324.27 / $2,068.46
| Professional | | $202.71 | $324.27 | $2,068.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.37 / $2,664.69 / $4,219.08
| Facility | | $394.37 | $2,664.69 | $4,219.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.57 / $2,220.57 / $3,434.86
| Professional | | $2,220.57 | $2,220.57 | $3,434.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.71 / $237.68 / $2,664.69
| Facility | | $202.71 | $237.68 | $2,664.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.71 / $271.48 / $2,664.69
| Professional | | $202.71 | $271.48 | $2,664.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.05 / $2,068.46 / $3,102.71
| Professional | | $1,965.05 | $2,068.46 | $3,102.71 |