- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,112.75 / $2,112.75 / $2,112.75
| Facility | | $2,112.75 | $2,112.75 | $2,112.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.11 / $2,112.75 / $2,112.75
| Professional | | $1,000.11 | $2,112.75 | $2,112.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.53 / $1,743.53 / $1,743.53
| Professional | | $1,743.53 | $1,743.53 | $1,743.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.55 / $1,300.55 / $2,329.91
| Facility | | $1,300.55 | $1,300.55 | $2,329.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.40 / $949.40 / $2,701.13
| Professional | | $949.40 | $949.40 | $2,701.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.24 / $1,038.36 / $1,608.86
| Professional | | $692.24 | $1,038.36 | $1,608.86 |