- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.55 / $1,008.55 / $1,008.55
| Facility | | $1,008.55 | $1,008.55 | $1,008.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.78 / $129.80 / $143.83
| Professional | | $122.78 | $129.80 | $143.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.40 / $206.59 / $224.51
| Facility | | $175.40 | $206.59 | $224.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.55 / $131.55 / $214.32
| Professional | | $131.55 | $131.55 | $214.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.53 / $465.53 / $465.53
| Facility | | $465.53 | $465.53 | $465.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.15 / $232.75 / $474.59
| Professional | | $87.15 | $232.75 | $474.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.67 / $105.24 / $280.64
| Professional | | $73.67 | $105.24 | $280.64 |