- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $389.05 / $1,148.15
| Professional | | $204.17 | $389.05 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,951.21
| Facility | | $2,454.71 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $316.23 / $794.33
| Professional | | $281.84 | $316.23 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $346.74 / $912.01
| Professional | | $251.19 | $346.74 | $912.01 |