- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $281.84 / $562.34
| Professional | | $169.82 | $281.84 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $398.11 / $1,148.15
| Professional | | $331.13 | $398.11 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $380.19 / $1,148.15
| Professional | | $234.42 | $380.19 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $407.38 / $758.58
| Professional | | $316.23 | $407.38 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $309.03 / $691.83
| Professional | | $199.53 | $309.03 | $691.83 |