- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,595.77 / $1,595.77 / $1,595.77
| Facility | | $1,595.77 | $1,595.77 | $1,595.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.77 / $2,178.35 / $8,905.17
| Professional | | $1,595.77 | $2,178.35 | $8,905.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $2,373.71
| Facility | | $2,373.71 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,373.71 / $2,373.71
| Professional | | $2,017.65 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,314.18 / $2,892.73 / $4,339.09
| Professional | | $2,314.18 | $2,892.73 | $4,339.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.27 / $860.27 / $2,373.71
| Facility | | $860.27 | $860.27 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,373.71 / $3,389.92
| Professional | | $2,017.65 | $2,373.71 | $3,389.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.05 / $1,332.55 / $2,039.16
| Professional | | $1,232.05 | $1,332.55 | $2,039.16 |