- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $5,203.09
| Professional | | $470.42 | $1,642.21 | $5,203.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $4,212.02 / $8,324.94
| Facility | | $1,642.21 | $4,212.02 | $8,324.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $5,203.09
| Professional | | $470.42 | $1,642.21 | $5,203.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,653.58 / $2,938.92 / $4,898.20
| Professional | | $2,653.58 | $2,938.92 | $4,898.20 |