- 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
- $912.01 / $1,023.29 / $2,344.23
| Professional | | $912.01 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,174.90 / $1,737.80
| Professional | | $891.25 | $1,174.90 | $1,737.80 |
- 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
- $794.33 / $1,071.52 / $1,698.24
| Professional | | $794.33 | $1,071.52 | $1,698.24 |