- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $4,562.39
| Professional | | $408.57 | $3,655.97 | $4,562.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.54 / $2,591.07 / $3,655.97
| Facility | | $303.54 | $2,591.07 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $4,562.39
| Professional | | $408.57 | $3,655.97 | $4,562.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.37 / $1,878.68 / $3,131.13
| Professional | | $1,685.37 | $1,878.68 | $3,131.13 |