- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.66 / $363.59 / $588.88
| Professional | | $349.66 | $363.59 | $588.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.68 / $508.07 / $1,177.09
| Professional | | $480.68 | $508.07 | $1,177.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.51 / $509.91 / $1,367.21
| Professional | | $324.51 | $509.91 | $1,367.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.63 / $849.63 / $1,003.32
| Professional | | $404.63 | $849.63 | $1,003.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.19 / $411.40 / $1,185.60
| Professional | | $302.19 | $411.40 | $1,185.60 |