- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,707.11 / $1,707.11 / $2,987.44
| Facility | | $1,707.11 | $1,707.11 | $2,987.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,707.11 / $1,707.11
| Professional | | $1,645.41 | $1,707.11 | $1,707.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.37 / $2,055.05 / $2,205.88
| Professional | | $1,885.37 | $2,055.05 | $2,205.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Facility | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,077.92 / $4,113.52 / $7,712.85
| Facility | | $2,077.92 | $4,113.52 | $7,712.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,815.69 / $7,815.69 / $9,255.42
| Professional | | $7,815.69 | $7,815.69 | $9,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $1,748.25
| Professional | | $1,713.97 | $1,713.97 | $1,748.25 |