- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.19 / $3,085.19 / $4,260.49
| Facility | | $3,085.19 | $3,085.19 | $4,260.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.14 / $2,375.10 / $3,085.19
| Professional | | $1,469.14 | $2,375.10 | $3,085.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.56 / $1,846.21 / $3,660.59
| Facility | | $1,591.56 | $1,846.21 | $3,660.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.69 / $2,203.69 / $2,203.69
| Facility | | $2,203.69 | $2,203.69 | $2,203.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,469.14 / $2,448.56
| Professional | | $1,028.40 | $1,469.14 | $2,448.56 |