- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $3,019.95
| Facility | | $1,288.25 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $3,019.95
| Professional | | $1,737.80 | $1,949.84 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Facility | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $7,079.46
| Facility | | $977.24 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $3,388.44
| Professional | | $1,412.54 | $1,995.26 | $3,388.44 |