- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.70 / $1,306.70 / $1,306.70
| Facility | | $1,306.70 | $1,306.70 | $1,306.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.72 / $1,306.70 / $1,951.86
| Professional | | $1,029.72 | $1,306.70 | $1,951.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $1,223.23 / $1,223.23
| Professional | | $124.05 | $1,223.23 | $1,223.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.51 / $814.56 / $1,453.42
| Facility | | $175.51 | $814.56 | $1,453.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.86 / $129.52 / $948.69
| Professional | | $94.86 | $129.52 | $948.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.83 / $708.28 / $1,167.83
| Professional | | $590.83 | $708.28 | $1,167.83 |