- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.44 / $2,448.44 / $3,381.19
| Facility | | $2,448.44 | $2,448.44 | $3,381.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.93 / $2,312.42 / $2,448.44
| Professional | | $1,165.93 | $2,312.42 | $2,448.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.08 / $1,465.18 / $3,486.13
| Facility | | $1,263.08 | $1,465.18 | $3,486.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.89 / $1,748.89 / $1,748.89
| Facility | | $1,748.89 | $1,748.89 | $1,748.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $1,954.77
| Professional | | $816.15 | $1,165.93 | $1,954.77 |