- 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
- $758.58 / $1,023.29 / $1,905.46
| Professional | | $758.58 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,348.96
| Professional | | $758.58 | $977.24 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $933.25 / $2,041.74
| Professional | | $776.25 | $933.25 | $2,041.74 |