- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,244.06 / $3,244.06 / $4,479.89
| Facility | | $3,244.06 | $3,244.06 | $4,479.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.79 / $3,063.83 / $3,244.06
| Professional | | $1,544.79 | $3,063.83 | $3,244.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.52 / $1,941.28 / $4,618.92
| Facility | | $1,673.52 | $1,941.28 | $4,618.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.19 / $2,317.19 / $2,317.19
| Facility | | $2,317.19 | $2,317.19 | $2,317.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,544.79 / $2,574.65
| Professional | | $1,081.34 | $1,544.79 | $2,574.65 |