- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,511.89
| Facility | | $2,238.72 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $575.44 / $1,778.28
| Facility | | $309.03 | $575.44 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $436.52 / $2,344.23
| Professional | | $316.23 | $436.52 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $436.52 / $467.74
| Facility | | $426.58 | $436.52 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $416.87 / $645.65
| Professional | | $316.23 | $416.87 | $645.65 |