- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.80 / $1,234.80 / $2,560.66
| Facility | | $1,234.80 | $1,234.80 | $2,560.66 |
- 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
- 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
- $2,215.42 / $5,201.60 / $7,712.85
| Facility | | $2,215.42 | $5,201.60 | $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 |