- 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
- $467.74 / $524.81 / $1,174.90
| Professional | | $467.74 | $524.81 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $616.60 / $891.25
| Professional | | $467.74 | $616.60 | $891.25 |
- 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 / $562.34 / $870.96
| Professional | | $407.38 | $562.34 | $870.96 |