- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,691.53 / $3,019.95
| Professional | | $1,479.11 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $3,981.07 / $3,981.07
| Professional | | $398.11 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $288.40 / $467.74
| Professional | | $177.83 | $288.40 | $467.74 |