- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $1,042.44 / $1,530.48
| Professional | | $119.94 | $1,042.44 | $1,530.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.82 / $464.63 / $1,229.27
| Facility | | $101.82 | $464.63 | $1,229.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $1,042.44 / $1,530.48
| Professional | | $119.94 | $1,042.44 | $1,530.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.79 / $714.14 / $1,190.24
| Professional | | $570.79 | $714.14 | $1,190.24 |