- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,076.22 / $5,933.81 / $7,635.66
| Facility | | $5,076.22 | $5,933.81 | $7,635.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $1,545.58
| Professional | | $1,545.58 | $1,545.58 | $1,545.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,009.25 / $2,009.25 / $2,009.25
| Facility | | $2,009.25 | $2,009.25 | $2,009.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |