- 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
- $707.95 / $776.25 / $1,862.09
| Professional | | $707.95 | $776.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $912.01 / $1,318.26
| Professional | | $660.69 | $912.01 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $1,288.25
| Professional | | $602.56 | $741.31 | $1,288.25 |