- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $177.83 / $575.44
| Professional | | $91.20 | $177.83 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,548.82
| Facility | | $1,202.26 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $125.89 / $354.81
| Professional | | $107.15 | $125.89 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $141.25 / $416.87
| Professional | | $107.15 | $141.25 | $416.87 |