- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,586.56 / $1,666.95 / $2,351.39
| Facility | | $1,586.56 | $1,666.95 | $2,351.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.56 / $1,808.52 / $2,351.39
| Professional | | $1,586.56 | $1,808.52 | $2,351.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.73 / $1,764.66 / $1,868.46
| Professional | | $1,411.73 | $1,764.66 | $1,868.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,334.00 / $4,334.00 / $4,334.00
| Facility | | $4,334.00 | $4,334.00 | $4,334.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.90 / $1,552.00 / $2,460.79
| Professional | | $1,204.90 | $1,552.00 | $2,460.79 |