- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $3,548.13
| Facility | | $2,238.72 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $549.54 / $645.65
| Professional | | $512.86 | $549.54 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $977.24
| Facility | | $812.83 | $912.01 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $467.74 / $1,148.15
| Professional | | $331.13 | $467.74 | $1,148.15 |