- 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
- $184.74 / $1,450.41 / $1,888.65
| Professional | | $184.74 | $1,450.41 | $1,888.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.04 / $251.30 / $2,636.14
| Facility | | $201.04 | $251.30 | $2,636.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,450.41 / $1,888.65
| Professional | | $184.74 | $1,450.41 | $1,888.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.73 / $1,100.01 / $1,833.35
| Professional | | $1,001.73 | $1,100.01 | $1,833.35 |