- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,651.22 / $3,302.44 / $6,604.86
| Facility | | $1,651.22 | $3,302.44 | $6,604.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.22 / $2,641.95 / $2,641.95
| Professional | | $1,651.22 | $2,641.95 | $2,641.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,529.63 / $3,162.03
| Professional | | $2,529.63 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,651.22 / $2,641.95 / $2,641.95
| Facility | | $1,651.22 | $2,641.95 | $2,641.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.33 / $1,805.33 / $2,201.62
| Professional | | $1,805.33 | $1,805.33 | $2,201.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $924.68 / $1,320.97
| Professional | | $924.68 | $924.68 | $1,320.97 |