- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $3,630.78
| Professional | | $1,380.38 | $1,995.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,090.30 / $3,630.78
| Professional | | $2,884.03 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $8,912.51
| Professional | | $2,754.23 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $2,511.89
| Professional | | $1,047.13 | $1,513.56 | $2,511.89 |