- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,980.87 / $3,980.87 / $5,497.39
| Facility | | $3,980.87 | $3,980.87 | $5,497.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.65 / $3,759.71 / $3,980.87
| Professional | | $1,895.65 | $3,759.71 | $3,980.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,053.62 / $2,382.19 / $5,667.99
| Facility | | $2,053.62 | $2,382.19 | $5,667.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,843.48 / $2,843.48 / $2,843.48
| Facility | | $2,843.48 | $2,843.48 | $2,843.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,895.65 / $3,159.42
| Professional | | $1,326.96 | $1,895.65 | $3,159.42 |