- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.01 / $1,644.01 / $1,644.01
| Facility | | $1,644.01 | $1,644.01 | $1,644.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.01 / $1,878.87 / $1,896.63
| Professional | | $1,644.01 | $1,878.87 | $1,896.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $2,381.07
| Facility | | $2,381.07 | $2,381.07 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $2,381.07 / $2,381.07
| Professional | | $1,738.18 | $2,381.07 | $2,381.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,633.08 / $2,494.36 / $17,752.32
| Facility | | $1,633.08 | $2,494.36 | $17,752.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.68 / $1,872.89 / $3,878.84
| Professional | | $1,132.68 | $1,872.89 | $3,878.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.68 / $1,826.35 / $2,618.15
| Professional | | $1,132.68 | $1,826.35 | $2,618.15 |