- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,877.12 / $2,877.12 / $2,877.12
| Facility | | $2,877.12 | $2,877.12 | $2,877.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.06 / $2,877.12 / $2,877.12
| Professional | | $1,713.06 | $2,877.12 | $2,877.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,469.19 / $2,469.19 / $2,469.19
| Professional | | $2,469.19 | $2,469.19 | $2,469.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $5,170.31
| Professional | | $287.76 | $2,837.98 | $5,170.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.61 / $1,523.27 / $2,265.31
| Professional | | $1,047.61 | $1,523.27 | $2,265.31 |