- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,308.31 / $3,308.31 / $3,308.31
| Facility | | $3,308.31 | $3,308.31 | $3,308.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,646.64 / $3,308.31 / $3,766.38
| Professional | | $2,646.64 | $3,308.31 | $3,766.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,019.14 / $4,019.14 / $7,756.94
| Facility | | $4,019.14 | $4,019.14 | $7,756.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,678.97 / $4,019.14 / $5,414.58
| Professional | | $2,678.97 | $4,019.14 | $5,414.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.01 / $695.15 / $8,427.82
| Facility | | $421.01 | $695.15 | $8,427.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.73 / $721.89 / $9,175.44
| Professional | | $534.73 | $721.89 | $9,175.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $5,305.26
| Professional | | $248.35 | $248.35 | $5,305.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $266.77 / $2,645.51
| Professional | | $151.16 | $266.77 | $2,645.51 |