- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $7,244.36
| Facility | | $2,041.74 | $2,041.74 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $831.76 / $1,995.26
| Professional | | $724.44 | $831.76 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $851.14 / $1,445.44
| Professional | | $602.56 | $851.14 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,511.89
| Facility | | $1,995.26 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $851.14 / $1,412.54
| Professional | | $645.65 | $851.14 | $1,412.54 |