- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,680.92 / $1,680.92 / $1,680.92
| Facility | | $1,680.92 | $1,680.92 | $1,680.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.92 / $1,921.05 / $1,966.53
| Professional | | $1,680.92 | $1,921.05 | $1,966.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.17 / $3,430.44 / $3,430.44
| Professional | | $2,334.17 | $3,430.44 | $3,430.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $3,214.74 / $3,214.74
| Professional | | $2,732.53 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.07 / $2,352.96 / $18,916.50
| Facility | | $1,165.07 | $2,352.96 | $18,916.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.11 / $2,384.78 / $3,965.93
| Professional | | $1,203.11 | $2,384.78 | $3,965.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.11 / $1,867.34 / $2,719.10
| Professional | | $1,203.11 | $1,867.34 | $2,719.10 |