- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.19 / $1,330.11 / $1,997.69
| Facility | | $1,032.19 | $1,330.11 | $1,997.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.54 / $343.54 / $477.82
| Professional | | $343.54 | $343.54 | $477.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.19 / $1,114.77 / $2,312.11
| Facility | | $1,032.19 | $1,114.77 | $2,312.11 |