- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,226.76 / $2,226.76 / $2,226.76
| Facility | | $2,226.76 | $2,226.76 | $2,226.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,622.35 / $2,226.76
| Professional | | $1,590.54 | $1,622.35 | $2,226.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $1,590.54 / $1,590.54
| Facility | | $1,500.51 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.60 / $1,686.89 / $2,550.00
| Facility | | $525.60 | $1,686.89 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.82 / $1,653.82 / $11,400.00
| Professional | | $1,653.82 | $1,653.82 | $11,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,306.28
| Professional | | $1,590.54 | $1,590.54 | $2,306.28 |