- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Facility | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.13 / $153.13 / $153.13
| Professional | | $153.13 | $153.13 | $153.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $1,794.93 / $1,902.62
| Facility | | $1,794.93 | $1,794.93 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $2,423.15
| Professional | | $1,902.62 | $1,902.62 | $2,423.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.23 / $1,617.23 / $2,273.14
| Professional | | $1,617.23 | $1,617.23 | $2,273.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $3,083.73
| Professional | | $1,902.62 | $1,902.62 | $3,083.73 |