- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $16,218.10
| Facility | | $7,244.36 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $3,981.07
| Professional | | $1,621.81 | $1,995.26 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $2,511.89
| Professional | | $1,621.81 | $2,187.76 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $4,168.69
| Professional | | $1,621.81 | $1,995.26 | $4,168.69 |