- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $467.74 / $1,047.13
| Professional | | $295.12 | $467.74 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $549.54 / $870.96
| Professional | | $346.74 | $549.54 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $630.96 / $812.83
| Professional | | $478.63 | $630.96 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $549.54 / $1,122.02
| Professional | | $398.11 | $549.54 | $1,122.02 |