- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.19 / $3,085.19 / $4,260.49
| Facility | | $3,085.19 | $3,085.19 | $4,260.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.14 / $2,375.10 / $3,085.19
| Professional | | $1,469.14 | $2,375.10 | $3,085.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.69 / $3,672.84 / $3,672.84
| Professional | | $2,203.69 | $3,672.84 | $3,672.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.56 / $3,158.73 / $4,590.43
| Facility | | $1,591.56 | $3,158.73 | $4,590.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.73 / $2,160.21 / $3,680.98
| Professional | | $999.73 | $2,160.21 | $3,680.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $2,301.65
| Professional | | $1,028.40 | $1,469.14 | $2,301.65 |