- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,523.06 / $1,523.06 / $1,523.06
| Facility | | $1,523.06 | $1,523.06 | $1,523.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.06 / $1,740.64 / $1,740.64
| Professional | | $1,523.06 | $1,740.64 | $1,740.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,425.11
| Facility | | $2,425.11 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,425.11 / $2,425.11
| Professional | | $1,770.33 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.02 / $2,132.00 / $16,380.05
| Facility | | $1,017.02 | $2,132.00 | $16,380.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.24 / $2,081.73 / $3,593.48
| Professional | | $1,050.24 | $2,081.73 | $3,593.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.24 / $1,680.38 / $2,373.05
| Professional | | $1,050.24 | $1,680.38 | $2,373.05 |