- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,944.26
| Professional | | $3,081.45 | $3,081.45 | $3,944.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.19 / $2,900.19 / $2,900.19
| Professional | | $2,900.19 | $2,900.19 | $2,900.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.22 / $1,376.08 / $1,777.82
| Professional | | $1,185.22 | $1,376.08 | $1,777.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,202.30
| Professional | | $3,021.04 | $3,021.04 | $3,202.30 |