- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,702.69 / $2,702.69 / $2,702.69
| Facility | | $2,702.69 | $2,702.69 | $2,702.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,702.69 / $2,702.69 / $2,702.69
| Professional | | $2,702.69 | $2,702.69 | $2,702.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,019.89 / $5,019.89 / $5,019.89
| Professional | | $5,019.89 | $5,019.89 | $5,019.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,049.05 / $3,049.05 / $9,652.32
| Professional | | $3,049.05 | $3,049.05 | $9,652.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.11 / $3,216.60 / $4,331.35
| Professional | | $1,923.11 | $3,216.60 | $4,331.35 |