- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $389.05 / $2,187.76
| Professional | | $323.59 | $389.05 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,630.78
| Facility | | $3,388.44 | $3,388.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $398.11 / $645.65
| Professional | | $288.40 | $398.11 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $426.58 / $1,174.90
| Professional | | $302.00 | $426.58 | $1,174.90 |