- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $5,334.20
| Facility | | $2,510.21 | $2,510.21 | $5,334.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.25 / $587.25 / $587.25
| Professional | | $587.25 | $587.25 | $587.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.08 / $1,004.08 / $1,631.63
| Professional | | $1,004.08 | $1,004.08 | $1,631.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $2,535.31
| Professional | | $2,510.21 | $2,510.21 | $2,535.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,510.21 / $4,066.54
| Facility | | $2,510.21 | $2,510.21 | $4,066.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.25 / $587.25 / $2,510.21
| Professional | | $587.25 | $587.25 | $2,510.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.21 / $1,506.13 / $3,765.32
| Professional | | $1,280.21 | $1,506.13 | $3,765.32 |