- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $3,691.56
| Professional | | $343.68 | $2,225.05 | $3,691.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.62 / $1,242.81 / $2,452.17
| Facility | | $245.62 | $1,242.81 | $2,452.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $3,691.56
| Professional | | $343.68 | $2,225.05 | $3,691.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.64 / $1,433.05 / $2,388.41
| Professional | | $1,186.64 | $1,433.05 | $2,388.41 |