- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,455.16 / $1,455.16 / $1,455.16
| Facility | | $1,455.16 | $1,455.16 | $1,455.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.16 / $1,663.04 / $1,663.04
| Professional | | $1,455.16 | $1,663.04 | $1,663.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $1,784.15 / $1,784.15
| Facility | | $1,784.15 | $1,784.15 | $1,784.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,784.15 / $1,784.15
| Professional | | $1,302.43 | $1,784.15 | $1,784.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.62 / $2,036.95 / $15,230.69
| Facility | | $919.62 | $2,036.95 | $15,230.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.65 / $1,882.36 / $3,433.28
| Professional | | $949.65 | $1,882.36 | $3,433.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.65 / $1,529.24 / $2,145.77
| Professional | | $949.65 | $1,529.24 | $2,145.77 |