- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.53 / $2,071.53 / $2,071.53
| Facility | | $2,071.53 | $2,071.53 | $2,071.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.18 / $220.84 / $1,148.00
| Professional | | $137.18 | $220.84 | $1,148.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.31 / $376.31 / $443.59
| Professional | | $376.31 | $376.31 | $443.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.35 / $241.57 / $797.83
| Professional | | $150.35 | $241.57 | $797.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.11 / $326.91 / $797.83
| Professional | | $201.11 | $326.91 | $797.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.16 / $337.46 / $979.25
| Professional | | $246.16 | $337.46 | $979.25 |