- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $4,219.56
| Professional | | $286.64 | $2,671.66 | $4,219.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.11 / $344.45 / $5,091.68
| Facility | | $239.11 | $344.45 | $5,091.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $4,219.56
| Professional | | $286.64 | $2,671.66 | $4,219.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.32 / $1,361.32 / $2,268.87
| Professional | | $1,361.32 | $1,361.32 | $2,268.87 |