- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,585.78
| Facility | | $7,244.36 | $7,244.36 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $2,398.83
| Professional | | $870.96 | $1,122.02 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $1,698.24
| Professional | | $831.76 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- 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 |