- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,552.10 / $2,552.10 / $2,552.10
| Facility | | $2,552.10 | $2,552.10 | $2,552.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.49 / $548.38 / $1,214.03
| Professional | | $296.49 | $548.38 | $1,214.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.93 / $844.93 / $2,453.03
| Professional | | $844.93 | $844.93 | $2,453.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.45 / $586.73 / $2,453.03
| Professional | | $351.45 | $586.73 | $2,453.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.42 / $864.61 / $2,453.03
| Professional | | $375.42 | $864.61 | $2,453.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.07 / $1,006.75 / $2,926.71
| Professional | | $755.07 | $1,006.75 | $2,926.71 |