- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,860.84 / $4,860.84 / $4,860.84
| Facility | | $4,860.84 | $4,860.84 | $4,860.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,218.82 / $4,860.84 / $7,346.95
| Professional | | $3,218.82 | $4,860.84 | $7,346.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $479.92 / $4,550.34
| Professional | | $422.50 | $479.92 | $4,550.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.54 / $3,784.56 / $7,346.95
| Facility | | $616.54 | $3,784.56 | $7,346.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.59 / $579.25 / $4,236.26
| Professional | | $384.59 | $579.25 | $4,236.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.59 / $3,123.63 / $4,548.27
| Professional | | $2,872.59 | $3,123.63 | $4,548.27 |