- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,025.60 / $6,025.60
| Facility | | $2,570.40 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,513.56 / $1,905.46
| Professional | | $1,412.54 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $1,819.70
| Professional | | $1,318.26 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $2,570.40
| Professional | | $1,819.70 | $2,187.76 | $2,570.40 |