- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,859.66 / $1,859.66 / $1,859.66
| Facility | | $1,859.66 | $1,859.66 | $1,859.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.66 / $2,262.21 / $2,262.21
| Professional | | $1,859.66 | $2,262.21 | $2,262.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.92 / $2,825.74 / $2,896.03
| Professional | | $2,389.92 | $2,825.74 | $2,896.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.25 / $3,162.56 / $3,976.69
| Professional | | $3,131.25 | $3,162.56 | $3,976.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.03 / $1,859.66 / $11,750.92
| Facility | | $1,151.03 | $1,859.66 | $11,750.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.30 / $1,691.66 / $2,067.15
| Professional | | $1,018.30 | $1,691.66 | $2,067.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.85 / $1,691.66 / $2,682.96
| Professional | | $751.85 | $1,691.66 | $2,682.96 |