- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $9,549.93 / $9,549.93
| Facility | | $6,165.95 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,479.11 / $1,737.80
| Professional | | $1,412.54 | $1,479.11 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,454.71 / $2,630.27
| Facility | | $2,187.76 | $2,454.71 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $3,090.30
| Professional | | $891.25 | $1,288.25 | $3,090.30 |