- 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
- $933.25 / $1,071.52 / $2,398.83
| Professional | | $933.25 | $1,071.52 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $758.58 / $1,479.11
| Professional | | $724.44 | $758.58 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $831.76 / $1,023.29
| Professional | | $676.08 | $831.76 | $1,023.29 |