- 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
- $2,344.23 / $2,630.27 / $6,309.57
| Professional | | $2,344.23 | $2,630.27 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $4,786.30
| Professional | | $2,137.96 | $2,818.38 | $4,786.30 |
- 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
- $2,238.72 / $2,691.53 / $4,168.69
| Professional | | $2,238.72 | $2,691.53 | $4,168.69 |