- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Facility | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $3,981.07
| Professional | | $2,041.74 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $186.21 / $186.21
| Professional | | $158.49 | $186.21 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $4,677.35
| Professional | | $1,288.25 | $1,819.70 | $4,677.35 |