- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.07 / $2,096.55 / $2,096.56
| Facility | | $1,588.07 | $2,096.55 | $2,096.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.78 / $2,096.56 / $2,147.08
| Professional | | $2,020.78 | $2,096.56 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.48 / $2,523.87 / $2,709.11
| Professional | | $2,315.48 | $2,523.87 | $2,709.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Facility | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.67 / $5,051.96 / $9,472.43
| Facility | | $2,399.67 | $5,051.96 | $9,472.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,840.93 / $9,598.71 / $11,366.91
| Professional | | $8,840.93 | $9,598.71 | $11,366.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $2,147.08
| Professional | | $2,104.98 | $2,104.98 | $2,147.08 |