- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $912.01 / $2,398.83
| Facility | | $891.25 | $912.01 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,897.79
| Professional | | $2,398.83 | $2,398.83 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $5,128.61
| Facility | | $2,398.83 | $2,511.89 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |