- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $19,498.45 / $19,498.45
| Facility | | $7,244.36 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,698.24 / $2,691.53
| Professional | | $977.24 | $1,698.24 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,318.26
| Professional | | $812.83 | $1,096.48 | $1,318.26 |
- 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
- $776.25 / $1,047.13 / $1,445.44
| Professional | | $776.25 | $1,047.13 | $1,445.44 |