- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,130.22 / $1,130.22 / $1,560.78
| Facility | | $1,130.22 | $1,130.22 | $1,560.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.77 / $1,130.22 / $1,130.22
| Professional | | $457.77 | $1,130.22 | $1,130.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.71 / $583.04 / $1,341.02
| Facility | | $219.71 | $583.04 | $1,341.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.46 / $1,030.84 / $1,348.15
| Professional | | $408.46 | $1,030.84 | $1,348.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.74 / $538.20 / $897.00
| Professional | | $376.74 | $538.20 | $897.00 |