- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,244.36
| Facility | | $6,606.93 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $2,238.72
| Professional | | $794.33 | $933.25 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $933.25 / $1,659.59
| Professional | | $776.25 | $933.25 | $1,659.59 |
- 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
- $776.25 / $1,096.48 / $1,584.89
| Professional | | $776.25 | $1,096.48 | $1,584.89 |