- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $3,467.37
| Professional | | $1,905.46 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $4,073.80 / $5,888.44
| Facility | | $588.84 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $17,782.79 / $17,782.79
| Professional | | $1,698.24 | $17,782.79 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $4,265.80
| Professional | | $1,819.70 | $2,630.27 | $4,265.80 |