- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $524.81 / $1,122.02
| Professional | | $407.38 | $524.81 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $457.09 / $758.58
| Professional | | $331.13 | $457.09 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $446.68 / $616.60
| Professional | | $338.84 | $446.68 | $616.60 |