- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,422.57 / $2,422.57 / $2,422.57
| Facility | | $2,422.57 | $2,422.57 | $2,422.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.40 / $2,422.57 / $2,422.57
| Professional | | $1,230.40 | $2,422.57 | $2,422.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.64 / $2,449.64 / $2,449.64
| Professional | | $2,449.64 | $2,449.64 | $2,449.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.95 / $1,758.95 / $1,758.95
| Professional | | $1,758.95 | $1,758.95 | $1,758.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.13 / $2,084.13 / $3,307.84
| Facility | | $2,084.13 | $2,084.13 | $3,307.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $2,084.13 / $2,896.46
| Professional | | $1,521.41 | $2,084.13 | $2,896.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.91 / $2,061.29 / $2,117.59
| Facility | | $1,815.91 | $2,061.29 | $2,117.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.13 / $1,437.76 / $2,117.59
| Professional | | $916.13 | $1,437.76 | $2,117.59 |