- 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
- $1,174.90 / $1,445.44 / $3,090.30
| Professional | | $1,174.90 | $1,445.44 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $2,187.76
| Professional | | $1,071.52 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $2,137.96
| Professional | | $1,071.52 | $1,348.96 | $2,137.96 |