- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,886.85 / $4,886.85 / $6,748.50
| Facility | | $4,886.85 | $4,886.85 | $6,748.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.07 / $3,762.10 / $4,886.85
| Professional | | $2,327.07 | $3,762.10 | $4,886.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,520.98 / $2,924.35 / $5,067.18
| Facility | | $2,520.98 | $2,924.35 | $5,067.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,490.61 / $3,490.61 / $3,490.61
| Facility | | $3,490.61 | $3,490.61 | $3,490.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $3,878.45
| Professional | | $1,628.95 | $2,327.07 | $3,878.45 |