- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,753.25 / $2,753.25 / $5,850.66
| Facility | | $2,753.25 | $2,753.25 | $5,850.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $455.43
| Professional | | $455.43 | $455.43 | $455.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.30 / $1,101.30 / $1,789.61
| Professional | | $1,101.30 | $1,101.30 | $1,789.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.25 / $2,753.25 / $2,780.78
| Professional | | $2,753.25 | $2,753.25 | $2,780.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,753.25 / $2,753.25 / $4,460.27
| Facility | | $2,753.25 | $2,753.25 | $4,460.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $2,753.25
| Professional | | $455.43 | $455.43 | $2,753.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.95 / $1,651.95 / $4,129.88
| Professional | | $1,651.95 | $1,651.95 | $4,129.88 |