- 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
- $478.63 / $524.81 / $1,288.25
| Professional | | $478.63 | $524.81 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $537.03 / $933.25
| Professional | | $407.38 | $537.03 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,318.26
| Facility | | $100.00 | $100.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $549.54 / $831.76
| Professional | | $436.52 | $549.54 | $831.76 |