- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.26 / $1,133.26 / $1,133.26
| Facility | | $1,133.26 | $1,133.26 | $1,133.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.33 / $516.30 / $1,133.26
| Professional | | $471.33 | $516.30 | $1,133.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.26 / $609.72 / $609.72
| Professional | | $518.26 | $609.72 | $609.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.12 / $587.79 / $909.19
| Professional | | $425.12 | $587.79 | $909.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.31 / $590.00 / $1,133.26
| Facility | | $458.31 | $590.00 | $1,133.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.16 / $625.88 / $3,624.69
| Professional | | $453.16 | $625.88 | $3,624.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.59 / $563.29 / $825.83
| Professional | | $448.59 | $563.29 | $825.83 |