- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $223.87 / $489.78
| Professional | | $151.36 | $223.87 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $302.00 / $446.68
| Professional | | $177.83 | $302.00 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $338.84 / $426.58
| Professional | | $257.04 | $338.84 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $288.40 / $602.56
| Professional | | $204.17 | $288.40 | $602.56 |