- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,921.65 / $2,038.50
| Facility | | $1,902.62 | $1,921.65 | $2,038.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $2,038.50
| Professional | | $1,902.62 | $1,902.62 | $2,038.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $3,672.06
| Facility | | $1,902.62 | $1,902.62 | $3,672.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,940.67
| Professional | | $1,902.62 | $1,902.62 | $1,940.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $1,902.62 / $1,902.62
| Facility | | $1,794.93 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,958.33 / $5,463.56 / $5,463.56
| Facility | | $4,958.33 | $5,463.56 | $5,463.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $2,173.55
| Professional | | $1,902.62 | $1,902.62 | $2,173.55 |