- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $2,511.89
| Professional | | $2,089.30 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $33.11 / $162.18
| Facility | | $33.11 | $33.11 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $162.18 / $173.78
| Professional | | $102.33 | $162.18 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,981.07 / $12,302.69
| Facility | | $3,548.13 | $3,981.07 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $5,623.41
| Professional | | $2,398.83 | $4,168.69 | $5,623.41 |