- 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
- $478.63 / $575.44 / $1,174.90
| Professional | | $478.63 | $575.44 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $724.44
| Professional | | $478.63 | $616.60 | $724.44 |
- 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
- $501.19 / $575.44 / $1,148.15
| Professional | | $501.19 | $575.44 | $1,148.15 |