- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,522.85 / $2,522.85 / $2,522.85
| Facility | | $2,522.85 | $2,522.85 | $2,522.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.71 / $2,516.40 / $2,522.85
| Professional | | $2,092.71 | $2,516.40 | $2,522.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.70 / $442.76 / $2,446.29
| Facility | | $249.70 | $442.76 | $2,446.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.70 / $285.01 / $2,634.47
| Professional | | $249.70 | $285.01 | $2,634.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,848.25 / $3,848.25 / $3,848.25
| Facility | | $3,848.25 | $3,848.25 | $3,848.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $16,093.06
| Professional | | $287.76 | $2,837.98 | $16,093.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.61 / $1,676.12 / $2,772.86
| Professional | | $1,309.61 | $1,676.12 | $2,772.86 |