- 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
- $851.14 / $1,047.13 / $1,380.38
| Professional | | $851.14 | $1,047.13 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $1,288.25
| Professional | | $295.12 | $812.83 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $380.19 / $776.25
| Professional | | $316.23 | $380.19 | $776.25 |