- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,010.31 / $2,010.31 / $2,010.31
| Facility | | $2,010.31 | $2,010.31 | $2,010.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.73 / $244.73 / $258.72
| Professional | | $244.73 | $244.73 | $258.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $370.60 / $411.78 / $430.03
| Facility | | $370.60 | $411.78 | $430.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.25 / $463.25 / $463.25
| Professional | | $463.25 | $463.25 | $463.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $419.54 / $419.54 / $419.54
| Facility | | $419.54 | $419.54 | $419.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.84 / $209.77 / $504.26
| Professional | | $146.84 | $209.77 | $504.26 |