- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,794.66 / $8,365.21 / $8,563.20
| Facility | | $6,794.66 | $8,365.21 | $8,563.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $2,643.84
| Professional | | $2,643.84 | $2,643.84 | $2,643.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.84 / $2,643.84 / $2,643.84
| Professional | | $2,643.84 | $2,643.84 | $2,643.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,257.51 / $2,257.51 / $2,257.51
| Facility | | $2,257.51 | $2,257.51 | $2,257.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.32 / $2,592.00 / $3,888.00
| Professional | | $2,488.32 | $2,592.00 | $3,888.00 |