- 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
- $676.08 / $776.25 / $1,905.46
| Professional | | $676.08 | $776.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $776.25 / $1,380.38
| Professional | | $575.44 | $776.25 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $1,230.27
| Professional | | $616.60 | $831.76 | $1,230.27 |