- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,105.36 / $6,105.36 / $6,105.36
| Facility | | $6,105.36 | $6,105.36 | $6,105.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.19 / $241.10 / $1,036.33
| Professional | | $168.19 | $241.10 | $1,036.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.03 / $339.55 / $734.44
| Professional | | $210.03 | $339.55 | $734.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.57 / $339.55 / $734.44
| Professional | | $253.57 | $339.55 | $734.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.36 / $278.24 / $901.44
| Professional | | $234.36 | $278.24 | $901.44 |