- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.36 / $1,642.36 / $1,642.36
| Facility | | $1,642.36 | $1,642.36 | $1,642.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.36 / $1,876.98 / $1,894.73
| Professional | | $1,642.36 | $1,876.98 | $1,894.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,463.07
| Facility | | $2,463.07 | $2,463.07 | $2,463.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,463.07 / $2,463.07
| Professional | | $1,798.04 | $2,463.07 | $2,463.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.49 / $2,298.98 / $17,730.55
| Facility | | $1,095.49 | $2,298.98 | $17,730.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.27 / $2,242.37 / $3,874.95
| Professional | | $1,131.27 | $2,242.37 | $3,874.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.27 / $1,824.50 / $2,556.16
| Professional | | $1,131.27 | $1,824.50 | $2,556.16 |