- 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 / $912.01 / $2,187.76
| Professional | | $851.14 | $912.01 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $1,621.81
| Professional | | $851.14 | $1,096.48 | $1,621.81 |
- 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
- $794.33 / $1,023.29 / $1,584.89
| Professional | | $794.33 | $1,023.29 | $1,584.89 |