- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,709.64 / $8,709.64
| Facility | | $5,623.41 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,348.96 / $1,584.89
| Professional | | $1,288.25 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $2,398.83
| Facility | | $1,995.26 | $2,238.72 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,818.38
| Professional | | $812.83 | $1,174.90 | $2,818.38 |