- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,513.56 / $3,890.45
| Facility | | $676.08 | $1,513.56 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $3,890.45
| Professional | | $2,137.96 | $3,388.44 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,454.71 / $3,548.13
| Facility | | $1,412.54 | $2,454.71 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,584.89 / $3,981.07
| Facility | | $467.74 | $1,584.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $7,079.46
| Professional | | $3,235.94 | $4,365.16 | $7,079.46 |