- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,159.34 / $1,159.34 / $1,159.34
| Facility | | $1,159.34 | $1,159.34 | $1,159.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.41 / $1,091.09 / $1,406.60
| Professional | | $828.41 | $1,091.09 | $1,406.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.75 / $264.81 / $1,579.81
| Facility | | $114.75 | $264.81 | $1,579.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.04 / $123.58 / $1,418.07
| Professional | | $105.04 | $123.58 | $1,418.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Facility | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $109.54 / $121.19
| Professional | | $93.11 | $109.54 | $121.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.07 / $126.34 / $773.16
| Professional | | $88.07 | $126.34 | $773.16 |