- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $2,894.88
| Professional | | $246.17 | $2,225.09 | $2,894.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.04 / $317.68 / $3,493.12
| Facility | | $164.04 | $317.68 | $3,493.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $2,894.88
| Professional | | $246.17 | $2,225.09 | $2,894.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.56 / $1,106.56 / $1,844.27
| Professional | | $1,106.56 | $1,106.56 | $1,844.27 |