- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,708.42 / $2,708.42 / $6,290.41
| Facility | | $2,708.42 | $2,708.42 | $6,290.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.87 / $1,029.06 / $1,053.85
| Professional | | $991.87 | $1,029.06 | $1,053.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Facility | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Professional | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,272.54 / $2,272.54 / $2,272.54
| Facility | | $2,272.54 | $2,272.54 | $2,272.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.87 / $1,033.20 / $1,674.59
| Professional | | $991.87 | $1,033.20 | $1,674.59 |