- 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
- $933.25 / $1,148.15 / $2,454.71
| Professional | | $933.25 | $1,148.15 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,174.90 / $1,698.24
| Professional | | $851.14 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $1,698.24
| Professional | | $831.76 | $1,071.52 | $1,698.24 |