- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,585.78
| Facility | | $7,244.36 | $7,244.36 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $2,818.38
| Professional | | $1,288.25 | $1,621.81 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,238.72
| Professional | | $1,445.44 | $1,737.80 | $2,238.72 |