- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.40 / $1,548.40 / $1,548.40
| Facility | | $1,548.40 | $1,548.40 | $1,548.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.09 / $1,370.66 / $1,548.40
| Professional | | $849.09 | $1,370.66 | $1,548.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.72 / $963.72 / $1,054.08
| Professional | | $963.72 | $963.72 | $1,054.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.87 / $109.87 / $109.87
| Facility | | $109.87 | $109.87 | $109.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $93.39 / $109.87
| Professional | | $93.39 | $93.39 | $109.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.79 / $104.37 / $851.28
| Professional | | $80.79 | $104.37 | $851.28 |