- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,678.70 / $3,678.70 / $5,080.10
| Facility | | $3,678.70 | $3,678.70 | $5,080.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.76 / $2,832.01 / $3,678.70
| Professional | | $1,751.76 | $2,832.01 | $3,678.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $2,201.38 / $5,237.76
| Facility | | $1,897.74 | $2,201.38 | $5,237.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,627.64 / $2,627.64 / $2,627.64
| Facility | | $2,627.64 | $2,627.64 | $2,627.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |