- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $4,365.16
| Facility | | $2,290.87 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $346.74 / $977.24
| Professional | | $74.13 | $346.74 | $977.24 |
- 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
- $5,495.41 / $5,495.41 / $5,495.41
| Professional | | $5,495.41 | $5,495.41 | $5,495.41 |
- 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 |