- 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
- $478.63 / $588.84 / $1,380.38
| Professional | | $478.63 | $588.84 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $562.34 / $1,023.29
| Professional | | $407.38 | $562.34 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,318.26
| Facility | | $100.00 | $100.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $602.56 / $891.25
| Professional | | $436.52 | $602.56 | $891.25 |