- 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
- $1,096.48 / $1,230.27 / $2,187.76
| Professional | | $1,096.48 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,089.30
| Professional | | $977.24 | $1,479.11 | $2,089.30 |
- 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
- $1,000.00 / $1,288.25 / $1,905.46
| Professional | | $1,000.00 | $1,288.25 | $1,905.46 |