- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,244.36
| Facility | | $4,897.79 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,570.40
| Professional | | $870.96 | $1,230.27 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $1,862.09
| Professional | | $912.01 | $1,230.27 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $1,862.09
| Professional | | $933.25 | $1,148.15 | $1,862.09 |