- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $7,762.47
| Facility | | $5,248.07 | $5,248.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $575.44 / $1,258.93
| Professional | | $354.81 | $575.44 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $1,513.56
| Professional | | $645.65 | $645.65 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $676.08 / $1,023.29
| Professional | | $398.11 | $676.08 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $794.33 / $954.99
| Professional | | $602.56 | $794.33 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $676.08 / $1,380.38
| Professional | | $489.78 | $676.08 | $1,380.38 |