- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $269.15 / $831.76
| Professional | | $208.93 | $269.15 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $398.11
| Professional | | $338.84 | $338.84 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $275.42 / $524.81
| Professional | | $223.87 | $275.42 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $302.00 / $870.96
| Professional | | $234.42 | $302.00 | $870.96 |