- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $5,495.41
| Facility | | $4,466.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,862.09 / $1,862.09
| Professional | | $1,819.70 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $4,466.84
| Facility | | $1,862.09 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,862.09 / $1,862.09
| Professional | | $1,819.70 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $15,488.17 / $26,302.68
| Facility | | $3,715.35 | $15,488.17 | $26,302.68 |