- 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
- $630.96 / $676.08 / $1,412.54
| Professional | | $630.96 | $676.08 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $707.95 / $851.14
| Professional | | $562.34 | $707.95 | $851.14 |
- 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
- $588.84 / $691.83 / $1,348.96
| Professional | | $588.84 | $691.83 | $1,348.96 |