- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $3,890.45
| Facility | | $1,513.56 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $338.84 / $407.38
| Professional | | $302.00 | $338.84 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $363.08 / $426.58
| Professional | | $331.13 | $363.08 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $478.63 / $588.84
| Professional | | $389.05 | $478.63 | $588.84 |