- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,484.42 / $3,484.42 / $3,484.42
| Facility | | $3,484.42 | $3,484.42 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,484.42 / $3,484.42 / $3,484.42
| Professional | | $3,484.42 | $3,484.42 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.46 / $2,645.46 / $2,645.46
| Professional | | $2,645.46 | $2,645.46 | $2,645.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.81 / $3,660.81 / $7,266.92
| Professional | | $3,660.81 | $3,660.81 | $7,266.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.56 / $1,965.08 / $8,951.57
| Professional | | $1,217.56 | $1,965.08 | $8,951.57 |