- 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
- $1,513.56 / $1,737.80 / $4,265.80
| Professional | | $1,513.56 | $1,737.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $2,951.21
| Professional | | $1,479.11 | $1,819.70 | $2,951.21 |
- 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
- $1,202.26 / $1,698.24 / $2,570.40
| Professional | | $1,202.26 | $1,698.24 | $2,570.40 |