- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,468.89 / $1,468.89 / $1,468.89
| Facility | | $1,468.89 | $1,468.89 | $1,468.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.12 / $1,468.89 / $1,468.89
| Professional | | $779.12 | $1,468.89 | $1,468.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.63 / $107.63 / $107.63
| Facility | | $107.63 | $107.63 | $107.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.49 / $107.63 / $144.13
| Professional | | $91.49 | $107.63 | $144.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.82 / $92.99 / $768.18
| Professional | | $53.82 | $92.99 | $768.18 |