- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.86 / $3,162.86 / $4,367.77
| Facility | | $3,162.86 | $3,162.86 | $4,367.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.13 / $2,434.90 / $3,162.86
| Professional | | $1,506.13 | $2,434.90 | $3,162.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $1,892.70 / $4,503.33
| Facility | | $1,631.64 | $1,892.70 | $4,503.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,259.19 / $2,259.19 / $2,259.19
| Facility | | $2,259.19 | $2,259.19 | $2,259.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,506.13 / $3,413.89
| Professional | | $1,054.29 | $1,506.13 | $3,413.89 |