- 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
- $2,691.53 / $3,019.95 / $7,079.46
| Professional | | $2,691.53 | $3,019.95 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $5,248.07
| Professional | | $2,398.83 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $954.99
| Facility | | $151.36 | $151.36 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $4,786.30
| Professional | | $2,454.71 | $3,019.95 | $4,786.30 |