- 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
- $977.24 / $1,148.15 / $2,754.23
| Professional | | $977.24 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,148.15 / $2,041.74
| Professional | | $891.25 | $1,148.15 | $2,041.74 |
- 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
- $933.25 / $1,202.26 / $1,905.46
| Professional | | $933.25 | $1,202.26 | $1,905.46 |