- 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
- $724.44 / $812.83 / $1,148.15
| Professional | | $724.44 | $812.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $707.95
| Professional | | $616.60 | $616.60 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $912.01 / $1,318.26
| Professional | | $758.58 | $912.01 | $1,318.26 |