- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.84 / $1,461.84 / $1,461.84
| Facility | | $1,461.84 | $1,461.84 | $1,461.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.84 / $1,670.67 / $1,670.67
| Professional | | $1,461.84 | $1,670.67 | $1,670.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $2,476.09 / $2,476.09
| Facility | | $2,476.09 | $2,476.09 | $2,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $2,476.09 / $2,476.09
| Professional | | $1,807.55 | $2,476.09 | $2,476.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.47 / $2,046.30 / $16,803.40
| Facility | | $1,023.47 | $2,046.30 | $16,803.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.89 / $2,094.92 / $3,449.03
| Professional | | $1,056.89 | $2,094.92 | $3,449.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.89 / $1,585.34 / $2,388.09
| Professional | | $1,056.89 | $1,585.34 | $2,388.09 |