- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,914.29 / $3,007.13 / $3,007.13
| Facility | | $1,914.29 | $3,007.13 | $3,007.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $3,007.13 / $3,007.13
| Professional | | $2,784.38 | $3,007.13 | $3,007.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,626.77 / $2,784.38
| Facility | | $2,626.77 | $2,626.77 | $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
- $110.16 / $572.40 / $1,986.50
| Facility | | $110.16 | $572.40 | $1,986.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.65 / $530.00 / $540.60
| Professional | | $92.65 | $530.00 | $540.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,070.34
| Professional | | $2,784.38 | $2,784.38 | $3,070.34 |