- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,097.44 / $3,097.44 / $3,097.44
| Facility | | $3,097.44 | $3,097.44 | $3,097.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.15 / $2,425.44 / $3,097.44
| Professional | | $1,316.15 | $2,425.44 | $3,097.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,298.10 / $4,298.10 / $4,298.10
| Professional | | $4,298.10 | $4,298.10 | $4,298.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,195.38 / $2,195.38 / $3,360.51
| Facility | | $2,195.38 | $2,195.38 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $3,637.50
| Professional | | $192.51 | $1,472.88 | $3,637.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $269.08 / $3,485.52
| Professional | | $108.80 | $269.08 | $3,485.52 |