- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,718.32 / $2,718.32 / $2,718.32
| Facility | | $2,718.32 | $2,718.32 | $2,718.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,568.04 / $2,718.32 / $4,884.42
| Professional | | $2,568.04 | $2,718.32 | $4,884.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $2,446.40
| Professional | | $286.94 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.59 / $3,060.40 / $4,884.42
| Facility | | $349.59 | $3,060.40 | $4,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.88 / $255.73 / $2,008.39
| Professional | | $104.88 | $255.73 | $2,008.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.76 / $1,887.44 / $2,887.24
| Professional | | $1,435.76 | $1,887.44 | $2,887.24 |