- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.96 / $2,460.96 / $2,460.96
| Facility | | $2,460.96 | $2,460.96 | $2,460.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.15 / $2,347.02 / $2,460.96
| Professional | | $1,316.15 | $2,347.02 | $2,460.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,544.80 / $3,544.80 / $3,544.80
| Professional | | $3,544.80 | $3,544.80 | $3,544.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $303.33 / $3,609.38
| Professional | | $192.51 | $303.33 | $3,609.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.47 / $211.06 / $2,222.42
| Professional | | $86.47 | $211.06 | $2,222.42 |