- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,698.24
| Facility | | $1,380.38 | $1,380.38 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,041.74
| Professional | | $1,096.48 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Professional | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $8,912.51
| Facility | | $2,884.03 | $2,884.03 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,467.37
| Professional | | $1,548.82 | $2,238.72 | $3,467.37 |