- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,496.79 / $1,496.79 / $1,496.79
| Facility | | $1,496.79 | $1,496.79 | $1,496.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.96 / $1,496.79 / $1,496.79
| Professional | | $1,443.96 | $1,496.79 | $1,496.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $482.77 / $864.65
| Facility | | $482.77 | $482.77 | $864.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.35 / $410.35 / $1,002.38
| Professional | | $410.35 | $410.35 | $1,002.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.95 / $433.70 / $598.70
| Professional | | $256.95 | $433.70 | $598.70 |