- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.57 / $1,060.57 / $1,060.57
| Facility | | $1,060.57 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.77 / $993.59 / $1,060.57
| Professional | | $433.77 | $993.59 | $1,060.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.66 / $101.66 / $793.22
| Facility | | $101.66 | $101.66 | $793.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.67 / $98.61 / $101.66
| Professional | | $83.67 | $98.61 | $101.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $917.98 / $1,060.57 / $1,792.36
| Facility | | $917.98 | $1,060.57 | $1,792.36 |