- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,683.31 / $1,683.31 / $1,683.31
| Facility | | $1,683.31 | $1,683.31 | $1,683.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.31 / $1,923.78 / $1,923.78
| Professional | | $1,683.31 | $1,923.78 | $1,923.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,435.32 / $3,435.32 / $3,435.32
| Professional | | $3,435.32 | $3,435.32 | $3,435.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $2,637.76
| Facility | | $2,637.76 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $2,637.76
| Professional | | $1,925.56 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.70 / $2,356.31 / $17,548.22
| Facility | | $1,067.70 | $2,356.31 | $17,548.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.57 / $2,185.48 / $3,971.56
| Professional | | $1,102.57 | $2,185.48 | $3,971.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.57 / $1,823.10 / $2,491.30
| Professional | | $1,102.57 | $1,823.10 | $2,491.30 |