- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,244.36
| Facility | | $7,079.46 | $7,079.46 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $3,981.07
| Professional | | $1,412.54 | $1,584.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,884.03
| Professional | | $1,230.27 | $1,621.81 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $5,128.61
| Facility | | $3,019.95 | $3,019.95 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $2,754.23
| Professional | | $1,348.96 | $1,737.80 | $2,754.23 |