- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,584.10 / $6,584.10 / $6,584.10
| Facility | | $6,584.10 | $6,584.10 | $6,584.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.25 / $2,597.60 / $10,633.92
| Professional | | $100.25 | $2,597.60 | $10,633.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.00 / $1,093.00 / $1,093.00
| Professional | | $1,093.00 | $1,093.00 | $1,093.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $599.00 / $2,530.00
| Facility | | $582.00 | $599.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $453.00 / $1,330.00
| Facility | | $418.00 | $453.00 | $1,330.00 |