- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.25 / $1,115.25 / $1,174.73
| Facility | | $1,115.25 | $1,115.25 | $1,174.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.47 / $1,115.25 / $1,483.54
| Professional | | $833.47 | $1,115.25 | $1,483.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.59 / $1,405.53 / $1,686.64
| Professional | | $1,116.59 | $1,405.53 | $1,686.64 |
- 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 / $91.49 / $107.63
| Professional | | $91.49 | $91.49 | $107.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $80.00 / $100.00
| Facility | | $64.00 | $80.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.72 / $87.18 / $903.24
| Professional | | $54.72 | $87.18 | $903.24 |