- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,907.00 / $7,899.00
| Facility | | $6,316.00 | $6,907.00 | $7,899.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.71 / $1,405.26 / $1,405.26
| Professional | | $1,370.71 | $1,405.26 | $1,405.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.92 / $1,513.14 / $2,589.26
| Professional | | $1,193.92 | $1,513.14 | $2,589.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,962.67 / $2,962.67 / $2,962.67
| Facility | | $2,962.67 | $2,962.67 | $2,962.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.07 / $1,557.16 / $3,160.88
| Professional | | $1,169.07 | $1,557.16 | $3,160.88 |