- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,943.28 / $7,943.28
| Facility | | $5,011.87 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,412.54
| Professional | | $1,148.15 | $1,230.27 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,995.26 / $2,137.96
| Facility | | $1,819.70 | $1,995.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $2,511.89
| Professional | | $724.44 | $1,047.13 | $2,511.89 |