- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $316.23 / $794.33
| Professional | | $281.84 | $316.23 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $912.01 / $1,071.52
| Professional | | $602.56 | $912.01 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $537.03 / $707.95
| Professional | | $416.87 | $537.03 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $10,471.29
| Facility | | $2,454.71 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $630.96 / $1,096.48
| Professional | | $354.81 | $630.96 | $1,096.48 |