- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,995.26 / $2,344.23
| Professional | | $1,949.84 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $1,862.09 / $1,949.84
| Facility | | $169.82 | $1,862.09 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $5,370.32
| Facility | | $1,905.46 | $2,290.87 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $6,760.83
| Professional | | $1,949.84 | $1,949.84 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $2,398.83
| Facility | | $1,621.81 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,995.26 / $1,995.26
| Professional | | $125.89 | $1,995.26 | $1,995.26 |