- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.49 / $1,046.49 / $1,046.49
| Facility | | $1,046.49 | $1,046.49 | $1,046.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.08 / $915.68 / $1,046.49
| Professional | | $872.08 | $915.68 | $1,046.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.83 / $872.08 / $872.08
| Facility | | $502.83 | $872.08 | $872.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.08 / $872.08 / $904.99
| Professional | | $872.08 | $872.08 | $904.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.87 / $872.08 / $898.24
| Professional | | $784.87 | $872.08 | $898.24 |