- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.16 / $1,005.16 / $1,005.16
| Facility | | $1,005.16 | $1,005.16 | $1,005.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.37 / $129.36 / $143.34
| Professional | | $122.37 | $129.36 | $143.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.30 / $205.89 / $215.02
| Facility | | $185.30 | $205.89 | $215.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.62 / $231.62 / $231.62
| Professional | | $231.62 | $231.62 | $231.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.85 / $139.85 / $139.85
| Professional | | $139.85 | $139.85 | $139.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $104.89 / $252.13
| Professional | | $73.42 | $104.89 | $252.13 |