- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $724.44 / $1,230.27
| Professional | | $602.56 | $724.44 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $724.44 / $1,258.93
| Professional | | $588.84 | $724.44 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $2,187.76
| Facility | | $1,258.93 | $1,258.93 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $676.08 / $1,000.00
| Professional | | $549.54 | $676.08 | $1,000.00 |