- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $1,047.13
| Professional | | $691.83 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,047.13 / $1,047.13
| Professional | | $602.56 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $3,019.95
| Professional | | $44.67 | $44.67 | $3,019.95 |