- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,441.89 / $2,441.89 / $3,372.14
| Facility | | $2,441.89 | $2,441.89 | $3,372.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.81 / $1,879.87 / $2,441.89
| Professional | | $1,162.81 | $1,879.87 | $2,441.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.71 / $1,461.26 / $3,476.80
| Facility | | $1,259.71 | $1,461.26 | $3,476.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.21 / $1,744.21 / $1,744.21
| Facility | | $1,744.21 | $1,744.21 | $1,744.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $1,162.81 / $1,938.01
| Professional | | $813.96 | $1,162.81 | $1,938.01 |