- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,068.10 / $3,068.10 / $4,236.89
| Facility | | $3,068.10 | $3,068.10 | $4,236.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.00 / $2,361.94 / $3,068.10
| Professional | | $1,461.00 | $2,361.94 | $3,068.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,582.75 / $1,835.99 / $3,181.33
| Facility | | $1,582.75 | $1,835.99 | $3,181.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,191.50 / $2,191.50 / $2,191.50
| Facility | | $2,191.50 | $2,191.50 | $2,191.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.70 / $1,461.00 / $2,435.00
| Professional | | $1,022.70 | $1,461.00 | $2,435.00 |