- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $575.44 / $2,630.27
| Professional | | $144.54 | $575.44 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,041.74
| Facility | | $1,862.09 | $1,862.09 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $446.68 / $1,258.93
| Professional | | $128.82 | $446.68 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $346.74 / $1,513.56
| Professional | | $144.54 | $346.74 | $1,513.56 |