- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,915.76 / $1,915.76 / $1,915.76
| Facility | | $1,915.76 | $1,915.76 | $1,915.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.86 / $1,915.76 / $1,915.76
| Professional | | $906.86 | $1,915.76 | $1,915.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.33 / $1,268.33 / $1,268.33
| Professional | | $1,268.33 | $1,268.33 | $1,268.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.28 / $1,327.28 / $2,465.48
| Facility | | $1,327.28 | $1,327.28 | $2,465.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.91 / $1,327.28 / $2,158.87
| Professional | | $968.91 | $1,327.28 | $2,158.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,407.34 / $2,407.34 / $2,832.16
| Facility | | $2,407.34 | $2,407.34 | $2,832.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.47 / $1,050.25 / $1,596.29
| Professional | | $706.47 | $1,050.25 | $1,596.29 |