- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,585.78 / $8,128.31
| Facility | | $7,244.36 | $7,585.78 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $4,786.30
| Professional | | $1,584.89 | $1,905.46 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $3,162.28
| Professional | | $1,513.56 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,691.53
| Professional | | $1,380.38 | $1,819.70 | $2,691.53 |