- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.58 / $1,285.58 / $1,339.88
| Facility | | $1,285.58 | $1,285.58 | $1,339.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.49 / $1,107.80 / $1,411.11
| Professional | | $909.49 | $1,107.80 | $1,411.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.55 / $512.50 / $685.43
| Facility | | $400.55 | $512.50 | $685.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.60 / $1,143.60 / $1,344.24
| Professional | | $1,143.60 | $1,143.60 | $1,344.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.33 / $396.70 / $1,988.61
| Professional | | $156.33 | $396.70 | $1,988.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.15 / $886.51 / $1,272.30
| Professional | | $647.15 | $886.51 | $1,272.30 |