- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,019.95 / $3,162.28
| Professional | | $1,148.15 | $3,019.95 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,309.57 / $7,585.78
| Facility | | $3,467.37 | $6,309.57 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,754.23 / $3,801.89
| Professional | | $1,737.80 | $2,754.23 | $3,801.89 |