- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,898.13 / $3,898.13 / $3,898.13
| Facility | | $3,898.13 | $3,898.13 | $3,898.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,840.07 / $3,898.13
| Professional | | $2,784.38 | $2,840.07 | $3,898.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,784.38 / $2,784.38
| Facility | | $2,626.77 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.10 / $540.60 / $1,519.09
| Facility | | $253.10 | $540.60 | $1,519.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.31 / $530.00 / $540.60
| Professional | | $430.31 | $530.00 | $540.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $4,037.35
| Professional | | $2,784.38 | $2,784.38 | $4,037.35 |