- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.35 / $3,467.39 / $6,657.39
| Facility | | $1,664.35 | $3,467.39 | $6,657.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.35 / $2,773.91 / $2,773.91
| Professional | | $1,664.35 | $2,773.91 | $2,773.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,331.48 / $2,108.17 / $2,773.91
| Facility | | $1,331.48 | $2,108.17 | $2,773.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.69 / $1,819.69 / $2,219.13
| Professional | | $1,819.69 | $1,819.69 | $2,219.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $932.03 / $1,331.48
| Professional | | $932.03 | $932.03 | $1,331.48 |