- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $1,659.59
| Facility | | $1,412.54 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $3,090.30
| Professional | | $1,659.59 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Facility | | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $457.09 / $616.60
| Professional | | $338.84 | $457.09 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |