- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.34 / $2,264.34 / $2,264.34
| Facility | | $2,264.34 | $2,264.34 | $2,264.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.52 / $536.86 / $781.51
| Professional | | $448.52 | $536.86 | $781.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $580.86 / $597.41 / $1,872.45
| Facility | | $580.86 | $597.41 | $1,872.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.44 / $780.98 / $1,243.11
| Professional | | $644.44 | $780.98 | $1,243.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.57 / $781.51 / $2,752.26
| Facility | | $679.57 | $781.51 | $2,752.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.97 / $733.28 / $814.76
| Professional | | $577.97 | $733.28 | $814.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.42 / $285.42 / $407.74
| Professional | | $285.42 | $285.42 | $407.74 |