- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,002.09 / $5,493.82 / $7,416.66
| Facility | | $3,002.09 | $5,493.82 | $7,416.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Facility | | $2,059.51 | $2,059.51 | $2,059.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Professional | | $2,059.51 | $2,059.51 | $2,059.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.36 / $2,048.92 / $2,277.23
| Facility | | $1,951.36 | $2,048.92 | $2,277.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,801.25 / $4,503.14
| Professional | | $1,260.88 | $1,801.25 | $4,503.14 |