- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,131.65 / $8,131.65 / $8,131.65
| Facility | | $8,131.65 | $8,131.65 | $8,131.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.34 / $340.11 / $1,260.00
| Professional | | $218.34 | $340.11 | $1,260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.91 / $427.71 / $1,101.47
| Professional | | $263.91 | $427.71 | $1,101.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.16 / $443.85 / $1,101.47
| Professional | | $332.16 | $443.85 | $1,101.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.91 / $406.42 / $1,351.94
| Professional | | $340.91 | $406.42 | $1,351.94 |