- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,244.36
| Facility | | $6,025.60 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $3,548.13
| Professional | | $1,258.93 | $1,445.44 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $2,511.89
| Professional | | $1,071.52 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,511.89
| Facility | | $1,995.26 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $2,238.72
| Professional | | $1,148.15 | $1,348.96 | $2,238.72 |