- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.76 / $1,096.76 / $1,096.76
| Facility | | $1,096.76 | $1,096.76 | $1,096.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.17 / $1,096.76 / $1,096.76
| Professional | | $519.17 | $1,096.76 | $1,096.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.10 / $905.10 / $905.10
| Professional | | $905.10 | $905.10 | $905.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.53 / $944.53 / $1,209.49
| Facility | | $944.53 | $944.53 | $1,209.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.51 / $944.53 / $1,059.07
| Professional | | $689.51 | $944.53 | $1,059.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.36 / $539.03 / $835.19
| Professional | | $359.36 | $539.03 | $835.19 |