- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,609.65 / $3,609.65 / $3,609.65
| Facility | | $3,609.65 | $3,609.65 | $3,609.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.10 / $3,609.65 / $4,560.82
| Professional | | $2,406.10 | $3,609.65 | $4,560.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $3,079.88
| Facility | | $2,399.94 | $2,399.94 | $3,079.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.16 / $2,399.94 / $2,471.94
| Professional | | $326.16 | $2,399.94 | $2,471.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,567.08 / $2,544.53 / $4,120.89
| Facility | | $1,567.08 | $2,544.53 | $4,120.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.49 / $391.49 / $412.09
| Professional | | $391.49 | $391.49 | $412.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.74 / $412.09 / $2,969.93
| Professional | | $222.74 | $412.09 | $2,969.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.63 / $2,035.62 / $3,223.07
| Professional | | $1,874.63 | $2,035.62 | $3,223.07 |