- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $7,523.16
| Professional | | $585.88 | $5,470.13 | $7,523.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,975.74 / $4,969.67 / $9,077.92
| Facility | | $3,975.74 | $4,969.67 | $9,077.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $7,523.16
| Professional | | $585.88 | $5,470.13 | $7,523.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.88 / $2,763.88 / $3,206.84
| Professional | | $2,763.88 | $2,763.88 | $3,206.84 |