- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,070.87 / $2,070.87 / $2,070.87
| Facility | | $2,070.87 | $2,070.87 | $2,070.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.72 / $517.72 / $517.72
| Professional | | $517.72 | $517.72 | $517.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.69 / $448.69 / $448.69
| Facility | | $448.69 | $448.69 | $448.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.89 / $1,069.95 / $1,125.17
| Professional | | $931.89 | $1,069.95 | $1,125.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.69 / $690.29 / $869.77
| Facility | | $448.69 | $690.29 | $869.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.26 / $828.35 / $959.50
| Professional | | $728.26 | $828.35 | $959.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.92 / $289.92 / $414.17
| Professional | | $289.92 | $289.92 | $414.17 |