- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $524.81 / $1,380.38
| Professional | | $501.19 | $524.81 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $660.69 / $758.58
| Professional | | $234.42 | $660.69 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $138.04
| Professional | | $109.65 | $109.65 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $1,737.80
| Professional | | $1,230.27 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $323.59 / $323.59
| Facility | | $263.03 | $323.59 | $323.59 |