- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,483.79 / $1,483.79 / $2,832.98
| Facility | | $1,483.79 | $1,483.79 | $2,832.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.54 / $343.54 / $343.54
| Professional | | $343.54 | $343.54 | $343.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,483.79 / $1,943.97 / $2,832.98
| Facility | | $1,483.79 | $1,943.97 | $2,832.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |