- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.50 / $1,091.50 / $1,091.50
| Facility | | $1,091.50 | $1,091.50 | $1,091.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.50 / $1,192.15 / $10,616.60
| Professional | | $1,091.50 | $1,192.15 | $10,616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $2,677.88
| Facility | | $2,677.88 | $2,677.88 | $2,677.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,677.88 / $2,854.76
| Professional | | $1,954.85 | $2,677.88 | $2,854.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.08 / $2,782.40 / $3,617.12
| Professional | | $1,725.08 | $2,782.40 | $3,617.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,337.38 / $3,722.05 / $3,722.05
| Facility | | $3,337.38 | $3,722.05 | $3,722.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.46 / $2,667.97 / $4,001.95
| Professional | | $2,119.46 | $2,667.97 | $4,001.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.57 / $1,690.72 / $2,425.56
| Professional | | $1,526.57 | $1,690.72 | $2,425.56 |