- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,548.13
| Facility | | $2,187.76 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,659.59 / $2,187.76
| Professional | | $1,174.90 | $1,659.59 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,047.13 / $1,445.44
| Professional | | $512.86 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,630.27
| Professional | | $2,187.76 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,187.76
| Professional | | $1,202.26 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $3,162.28
| Professional | | $1,318.26 | $2,187.76 | $3,162.28 |