- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,316.80 / $1,316.80 / $1,316.80
| Facility | | $1,316.80 | $1,316.80 | $1,316.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.89 / $1,268.88 / $1,316.80
| Professional | | $1,030.89 | $1,268.88 | $1,316.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,646.45 / $4,646.45 / $5,402.14
| Facility | | $4,646.45 | $4,646.45 | $5,402.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.12 / $1,380.09 / $1,694.58
| Professional | | $889.12 | $1,380.09 | $1,694.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.63 / $1,694.58 / $1,694.58
| Professional | | $681.63 | $1,694.58 | $1,694.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.53 / $1,680.83 / $3,699.34
| Professional | | $1,272.53 | $1,680.83 | $3,699.34 |