- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,754.40 / $5,754.40
| Facility | | $3,630.78 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $891.25 / $1,047.13
| Professional | | $831.76 | $891.25 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $1,819.70
| Professional | | $537.03 | $758.58 | $1,819.70 |