- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.27 / $1,800.27 / $1,857.07
| Facility | | $1,800.27 | $1,800.27 | $1,857.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $2,042.77
| Professional | | $1,857.07 | $1,857.07 | $2,042.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,835.74 / $1,835.74 / $44,999.55
| Facility | | $1,835.74 | $1,835.74 | $44,999.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $2,039.14 / $2,039.14
| Facility | | $1,857.07 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,774.68
| Professional | | $2,039.14 | $2,039.14 | $2,774.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $2,123.77 / $2,394.48
| Professional | | $1,875.28 | $2,123.77 | $2,394.48 |