- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,244.36
| Facility | | $4,897.79 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $575.44 / $1,318.26
| Professional | | $436.52 | $575.44 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $575.44 / $831.76
| Professional | | $457.09 | $575.44 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $524.81 / $812.83
| Professional | | $407.38 | $524.81 | $812.83 |