- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,764.36 / $2,764.36 / $2,764.36
| Facility | | $2,764.36 | $2,764.36 | $2,764.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.05 / $2,764.36 / $3,825.75
| Professional | | $1,979.05 | $2,764.36 | $3,825.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $2,291.84
| Professional | | $246.17 | $2,225.09 | $2,291.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.68 / $2,132.48 / $3,825.75
| Facility | | $317.68 | $2,132.48 | $3,825.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.32 / $192.40 / $1,405.59
| Professional | | $117.32 | $192.40 | $1,405.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.56 / $1,139.00 / $2,016.78
| Professional | | $1,106.56 | $1,139.00 | $2,016.78 |