- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,730.62 / $2,730.62 / $3,276.74
| Facility | | $2,730.62 | $2,730.62 | $3,276.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.31 / $2,730.62 / $2,837.73
| Professional | | $1,732.31 | $2,730.62 | $2,837.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,751.98 / $1,751.98
| Professional | | $1,751.98 | $1,751.98 | $1,751.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $1,472.88
| Professional | | $192.51 | $1,472.88 | $1,472.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.82 / $224.62 / $2,072.35
| Professional | | $109.82 | $224.62 | $2,072.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.57 / $3,470.82 / $4,417.41
| Professional | | $3,132.57 | $3,470.82 | $4,417.41 |