- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.03 / $1,646.03 / $1,646.03
| Facility | | $1,646.03 | $1,646.03 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $1,646.03
| Professional | | $588.62 | $588.62 | $1,646.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.47 / $327.16 / $809.07
| Facility | | $138.47 | $327.16 | $809.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.63 / $173.10 / $408.94
| Professional | | $140.63 | $173.10 | $408.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.62 / $1,646.03 / $3,341.44
| Facility | | $588.62 | $1,646.03 | $3,341.44 |