- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $2,560.66
| Facility | | $1,748.25 | $1,748.25 | $2,560.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,707.11 / $1,748.25
| Professional | | $1,645.41 | $1,707.11 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.73 / $2,195.08 / $3,942.13
| Facility | | $1,076.73 | $2,195.08 | $3,942.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.13 / $1,713.97 / $1,748.24
| Professional | | $1,641.13 | $1,713.97 | $1,748.24 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $2,056.76
| Professional | | $1,713.97 | $1,713.97 | $2,056.76 |