- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.10 / $1,012.10 / $1,012.10
| Facility | | $1,012.10 | $1,012.10 | $1,012.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.63 / $1,012.10 / $1,333.52
| Professional | | $830.63 | $1,012.10 | $1,333.52 |
- 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 / $141.27
| Professional | | $91.49 | $107.63 | $141.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.13 / $1,012.10 / $1,333.52
| Facility | | $177.13 | $1,012.10 | $1,333.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.00 / $280.00 / $280.00
| Professional | | $144.00 | $280.00 | $280.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.98 / $90.65 / $874.51
| Professional | | $60.98 | $90.65 | $874.51 |