- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,270.75 / $5,270.75 / $7,278.65
| Facility | | $5,270.75 | $5,270.75 | $7,278.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,509.88 / $4,057.64 / $5,270.75
| Professional | | $2,509.88 | $4,057.64 | $5,270.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.03 / $3,154.07 / $5,465.25
| Facility | | $2,719.03 | $3,154.07 | $5,465.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,764.82 / $3,764.82 / $3,764.82
| Facility | | $3,764.82 | $3,764.82 | $3,764.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.91 / $2,509.88 / $4,183.13
| Professional | | $1,756.91 | $2,509.88 | $4,183.13 |