- 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
- $2,754.23 / $3,235.94 / $5,623.41
| Professional | | $2,754.23 | $3,235.94 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $5,370.32
| Professional | | $2,511.89 | $3,090.30 | $5,370.32 |
- 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
- $2,398.83 / $2,951.21 / $4,265.80
| Professional | | $2,398.83 | $2,951.21 | $4,265.80 |