- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $3,235.94
| Professional | | $1,513.56 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $489.78 / $512.86
| Professional | | $416.87 | $489.78 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,890.45
| Professional | | $1,047.13 | $1,513.56 | $3,890.45 |