- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $204.17 / $912.01
| Professional | | $87.10 | $204.17 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,691.53
| Facility | | $2,187.76 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $186.21 / $776.25
| Professional | | $141.25 | $186.21 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $302.00 / $891.25
| Professional | | $120.23 | $302.00 | $891.25 |