- 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
- $588.84 / $691.83 / $1,148.15
| Professional | | $588.84 | $691.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $758.58 / $1,148.15
| Professional | | $549.54 | $758.58 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $323.59 / $954.99
| Facility | | $151.36 | $323.59 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $933.25
| Professional | | $512.86 | $645.65 | $933.25 |