- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,420.17 / $2,420.17 / $2,420.17
| Facility | | $2,420.17 | $2,420.17 | $2,420.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.16 / $115.20 / $132.46
| Professional | | $112.16 | $115.20 | $132.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.61 / $482.61 / $482.61
| Facility | | $482.61 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $410.22 / $482.61
| Professional | | $410.22 | $410.22 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.21 / $255.35 / $376.59
| Professional | | $153.21 | $255.35 | $376.59 |