- 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
- $1,288.25 / $1,584.89 / $3,162.28
| Professional | | $1,288.25 | $1,584.89 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $1,995.26
| Professional | | $1,288.25 | $1,621.81 | $1,995.26 |
- 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
- $1,202.26 / $1,380.38 / $3,090.30
| Professional | | $1,202.26 | $1,380.38 | $3,090.30 |