- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,250.36 / $2,250.36 / $2,700.43
| Facility | | $2,250.36 | $2,250.36 | $2,700.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.30 / $2,250.36 / $2,338.66
| Professional | | $1,581.30 | $2,250.36 | $2,338.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,750.77 / $1,750.77 / $1,750.77
| Professional | | $1,750.77 | $1,750.77 | $1,750.77 |
- 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 / $257.83 / $303.33
| Professional | | $192.51 | $257.83 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.33 / $196.06 / $1,707.85
| Professional | | $100.33 | $196.06 | $1,707.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,839.58 / $3,146.19 / $4,004.24
| Professional | | $2,839.58 | $3,146.19 | $4,004.24 |