- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.78 / $1,717.78 / $1,717.78
| Facility | | $1,717.78 | $1,717.78 | $1,717.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,717.78 / $1,717.78
| Professional | | $1,590.54 | $1,717.78 | $1,717.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $1,500.51 / $1,590.54
| Facility | | $1,500.51 | $1,500.51 | $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
- $1,653.82 / $1,875.43 / $3,000.00
| Facility | | $1,653.82 | $1,875.43 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.32 / $1,653.82 / $11,400.00
| Professional | | $1,589.32 | $1,653.82 | $11,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.51 / $1,590.54 / $1,853.66
| Professional | | $1,528.51 | $1,590.54 | $1,853.66 |