- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,513.56
| Professional | | $1,230.27 | $1,230.27 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $645.65 / $851.14
| Facility | | $426.58 | $645.65 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,288.25 / $1,659.59
| Facility | | $1,230.27 | $1,288.25 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,174.90 / $2,041.74
| Facility | | $346.74 | $1,174.90 | $2,041.74 |