- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,241.16 / $1,241.16 / $1,241.16
| Facility | | $1,241.16 | $1,241.16 | $1,241.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.16 / $1,418.46 / $1,452.09
| Professional | | $1,241.16 | $1,418.46 | $1,452.09 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $860.27 / $1,737.39 / $13,967.65
| Facility | | $860.27 | $1,737.39 | $13,967.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.36 / $1,760.88 / $2,928.37
| Professional | | $888.36 | $1,760.88 | $2,928.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.36 / $1,344.99 / $2,007.29
| Professional | | $888.36 | $1,344.99 | $2,007.29 |