- 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
- $645.65 / $676.08 / $1,737.80
| Professional | | $645.65 | $676.08 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $1,202.26
| Professional | | $630.96 | $794.33 | $1,202.26 |
- 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
- $588.84 / $776.25 / $1,174.90
| Professional | | $588.84 | $776.25 | $1,174.90 |