- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.57 / $5,043.35 / $8,343.60
| Facility | | $1,044.57 | $5,043.35 | $8,343.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.45 / $432.30 / $465.85
| Professional | | $406.45 | $432.30 | $465.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.11 / $560.52 / $799.97
| Professional | | $416.11 | $560.52 | $799.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,840.78 / $6,840.78 / $6,840.78
| Facility | | $6,840.78 | $6,840.78 | $6,840.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.37 / $575.45 / $1,050.54
| Professional | | $440.37 | $575.45 | $1,050.54 |