- 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
- $1,288.25 / $1,479.11 / $2,570.40
| Professional | | $1,288.25 | $1,479.11 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $2,511.89
| Professional | | $1,122.02 | $1,445.44 | $2,511.89 |
- 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
- $1,096.48 / $1,348.96 / $1,995.26
| Professional | | $1,096.48 | $1,348.96 | $1,995.26 |