- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,253.55 / $1,253.55 / $1,253.55
| Facility | | $1,253.55 | $1,253.55 | $1,253.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.19 / $495.67 / $827.08
| Professional | | $373.19 | $495.67 | $827.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.57 / $744.52 / $1,063.59
| Professional | | $407.57 | $744.52 | $1,063.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.85 / $625.10 / $1,286.08
| Professional | | $447.85 | $625.10 | $1,286.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.71 / $678.69 / $1,018.25
| Professional | | $539.71 | $678.69 | $1,018.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.60 / $561.13 / $1,195.38
| Professional | | $402.60 | $561.13 | $1,195.38 |