- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.38 / $1,348.38 / $1,348.38
| Facility | | $1,348.38 | $1,348.38 | $1,348.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.38 / $1,541.01 / $1,541.01
| Professional | | $1,348.38 | $1,541.01 | $1,541.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $2,479.82
| Facility | | $2,479.82 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $2,479.82 / $2,479.82
| Professional | | $1,810.27 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.71 / $1,887.49 / $16,444.91
| Facility | | $1,000.71 | $1,887.49 | $16,444.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.39 / $2,048.35 / $3,181.35
| Professional | | $1,033.39 | $2,048.35 | $3,181.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.39 / $1,550.09 / $2,334.98
| Professional | | $1,033.39 | $1,550.09 | $2,334.98 |