- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,244.36
| Facility | | $6,606.93 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $4,265.80
| Professional | | $1,513.56 | $1,778.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $3,162.28
| Professional | | $1,380.38 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $2,951.21
| Professional | | $1,445.44 | $1,862.09 | $2,951.21 |