- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,059.22 / $1,059.22 / $1,462.73
| Facility | | $1,059.22 | $1,059.22 | $1,462.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.39 / $1,059.22 / $1,059.22
| Professional | | $504.39 | $1,059.22 | $1,059.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $546.41 / $633.85 / $1,508.12
| Facility | | $546.41 | $633.85 | $1,508.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.01 / $966.01 / $1,207.51
| Professional | | $966.01 | $966.01 | $1,207.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.07 / $504.39 / $840.65
| Professional | | $353.07 | $504.39 | $840.65 |