- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $4,466.84
| Professional | | $2,187.76 | $2,570.40 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $4,265.80
| Professional | | $1,862.09 | $2,511.89 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $323.59 / $954.99
| Facility | | $151.36 | $323.59 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $3,388.44
| Professional | | $1,862.09 | $2,344.23 | $3,388.44 |