- 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
- $954.99 / $1,380.38 / $2,818.38
| Professional | | $954.99 | $1,380.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,041.74
| Professional | | $1,000.00 | $1,348.96 | $2,041.74 |
- 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
- $977.24 / $1,258.93 / $1,995.26
| Professional | | $977.24 | $1,258.93 | $1,995.26 |