- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,414.54 / $3,414.54 / $4,715.31
| Facility | | $3,414.54 | $3,414.54 | $4,715.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.97 / $3,224.84 / $3,414.54
| Professional | | $1,625.97 | $3,224.84 | $3,414.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,761.47 / $2,043.31 / $4,861.66
| Facility | | $1,761.47 | $2,043.31 | $4,861.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,438.96 / $2,438.96 / $2,438.96
| Facility | | $2,438.96 | $2,438.96 | $2,438.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,625.97 / $2,726.07
| Professional | | $1,138.18 | $1,625.97 | $2,726.07 |