- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,587.72 / $1,587.72 / $1,587.72
| Facility | | $1,587.72 | $1,587.72 | $1,587.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,587.72 / $1,814.53 / $1,841.56
| Professional | | $1,587.72 | $1,814.53 | $1,841.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $2,717.61
| Facility | | $2,717.61 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $2,717.61
| Professional | | $1,983.86 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.82 / $2,222.50 / $19,464.45
| Facility | | $1,191.82 | $2,222.50 | $19,464.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.74 / $2,439.53 / $3,746.03
| Professional | | $1,230.74 | $2,439.53 | $3,746.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.74 / $1,769.05 / $2,780.91
| Professional | | $1,230.74 | $1,769.05 | $2,780.91 |