- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,223.72 / $1,430.01 / $2,306.56
| Facility | | $1,223.72 | $1,430.01 | $2,306.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.25 / $744.37 / $845.88
| Professional | | $509.25 | $744.37 | $845.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.42 / $1,241.42 / $1,241.42
| Professional | | $1,241.42 | $1,241.42 | $1,241.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $383.91 / $383.91 / $383.91
| Facility | | $383.91 | $383.91 | $383.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.89 / $726.91 / $1,241.42
| Professional | | $543.89 | $726.91 | $1,241.42 |