- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,499.54 / $1,499.54 / $1,499.54
| Facility | | $1,499.54 | $1,499.54 | $1,499.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.45 / $563.61 / $873.65
| Professional | | $536.45 | $563.61 | $873.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.38 / $441.38 / $441.38
| Facility | | $441.38 | $441.38 | $441.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.36 / $1,498.36 / $1,872.96
| Professional | | $1,498.36 | $1,498.36 | $1,872.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.20 / $407.43 / $1,493.91
| Professional | | $285.20 | $407.43 | $1,493.91 |