- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,495.41 / $6,025.60
| Facility | | $3,019.95 | $5,495.41 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,311.31
| Professional | | $1,995.26 | $2,344.23 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,041.74 / $2,290.87
| Facility | | $1,949.84 | $2,041.74 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,630.78
| Facility | | $2,691.53 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $6,760.83
| Professional | | $1,258.93 | $1,819.70 | $6,760.83 |