- 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
- $416.87 / $478.63 / $831.76
| Professional | | $416.87 | $478.63 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $489.78 / $851.14
| Professional | | $354.81 | $489.78 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $416.87 / $1,318.26
| Facility | | $100.00 | $416.87 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $446.68 / $645.65
| Professional | | $363.08 | $446.68 | $645.65 |