- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $4,610.87
| Professional | | $415.13 | $3,248.38 | $4,610.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,986.09 / $3,883.81 / $7,377.39
| Facility | | $2,986.09 | $3,883.81 | $7,377.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $4,610.87
| Professional | | $415.13 | $3,248.38 | $4,610.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.54 / $2,596.26 / $4,327.10
| Professional | | $2,351.54 | $2,596.26 | $4,327.10 |