- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,003.38 / $1,468.37 / $1,468.37
| Facility | | $1,003.38 | $1,468.37 | $1,468.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.38 / $1,040.08 / $1,468.37
| Professional | | $1,003.38 | $1,040.08 | $1,468.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.64 / $840.64 / $841.00
| Facility | | $840.64 | $840.64 | $841.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.31 / $1,040.08 / $1,040.08
| Facility | | $329.31 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Professional | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.91 / $1,019.70 / $1,325.61
| Professional | | $978.91 | $1,019.70 | $1,325.61 |