- 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
- $1,348.96 / $1,949.84 / $3,981.07
| Professional | | $1,348.96 | $1,949.84 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,754.23
| Professional | | $1,318.26 | $1,862.09 | $2,754.23 |
- 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
- $1,230.27 / $1,621.81 / $2,454.71
| Professional | | $1,230.27 | $1,621.81 | $2,454.71 |