- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,769.92 / $2,769.92 / $3,825.13
| Facility | | $2,769.92 | $2,769.92 | $3,825.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.01 / $2,616.04 / $2,769.92
| Professional | | $1,319.01 | $2,616.04 | $2,769.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.93 / $1,657.56 / $3,943.85
| Facility | | $1,428.93 | $1,657.56 | $3,943.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.52 / $1,978.52 / $1,978.52
| Facility | | $1,978.52 | $1,978.52 | $1,978.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $2,198.35
| Professional | | $923.31 | $1,319.01 | $2,198.35 |