- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $4,685.85 / $5,149.30
| Facility | | $2,574.65 | $4,685.85 | $5,149.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.97 / $4,685.85 / $5,149.30
| Professional | | $2,033.97 | $4,685.85 | $5,149.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $2,574.65
| Facility | | $2,574.65 | $2,574.65 | $2,574.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $2,574.65
| Professional | | $2,574.65 | $2,574.65 | $2,574.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,544.79 / $4,131.14
| Professional | | $1,081.34 | $1,544.79 | $4,131.14 |