- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,250.38 / $1,250.38 / $1,250.38
| Facility | | $1,250.38 | $1,250.38 | $1,250.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.50 / $494.64 / $812.18
| Professional | | $387.50 | $494.64 | $812.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.74 / $751.17 / $1,091.35
| Professional | | $411.74 | $751.17 | $1,091.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.96 / $627.29 / $1,328.82
| Professional | | $465.96 | $627.29 | $1,328.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.67 / $689.53 / $1,016.02
| Professional | | $545.67 | $689.53 | $1,016.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.34 / $590.71 / $1,283.43
| Professional | | $396.34 | $590.71 | $1,283.43 |