- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.48 / $1,981.48 / $1,981.48
| Facility | | $1,981.48 | $1,981.48 | $1,981.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.48 / $1,981.48 / $2,264.54
| Professional | | $1,981.48 | $1,981.48 | $2,264.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,297.04 / $4,043.83 / $4,043.83
| Professional | | $3,297.04 | $4,043.83 | $4,043.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $2,481.10
| Facility | | $2,481.10 | $2,481.10 | $2,481.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $2,481.10 / $2,481.10
| Professional | | $1,811.20 | $2,481.10 | $2,481.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.53 / $2,773.68 / $20,983.29
| Facility | | $1,270.53 | $2,773.68 | $20,983.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.02 / $2,600.65 / $4,675.06
| Professional | | $1,312.02 | $2,600.65 | $4,675.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.35 / $2,600.65 / $2,965.23
| Facility | | $1,516.35 | $2,600.65 | $2,965.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.02 / $2,147.23 / $2,964.57
| Professional | | $1,312.02 | $2,147.23 | $2,964.57 |