- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,172.67 / $2,172.67 / $2,172.67
| Facility | | $2,172.67 | $2,172.67 | $2,172.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.48 / $603.10 / $2,281.23
| Professional | | $441.48 | $603.10 | $2,281.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.65 / $675.65 / $675.65
| Facility | | $675.65 | $675.65 | $675.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.65 / $675.65 / $717.02
| Professional | | $358.65 | $675.65 | $717.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.03 / $460.67 / $708.19
| Facility | | $335.03 | $460.67 | $708.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.70 / $674.54 / $910.62
| Professional | | $404.70 | $674.54 | $910.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.58 / $715.73 / $880.44
| Professional | | $615.58 | $715.73 | $880.44 |