- 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
- $1,380.38 / $1,621.81 / $2,818.38
| Professional | | $1,380.38 | $1,621.81 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $2,754.23
| Professional | | $1,202.26 | $1,548.82 | $2,754.23 |
- 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
- $1,174.90 / $1,479.11 / $2,187.76
| Professional | | $1,174.90 | $1,479.11 | $2,187.76 |