- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,949.84
| Facility | | $1,318.26 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,348.96 / $1,621.81
| Professional | | $1,288.25 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $42.66 / $67.61
| Professional | | $21.38 | $42.66 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,288.25 / $1,380.38
| Professional | | $125.89 | $1,288.25 | $1,380.38 |