- 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
- $1,995.26 / $2,290.87 / $5,623.41
| Professional | | $1,995.26 | $2,290.87 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $3,801.89
| Professional | | $1,949.84 | $2,691.53 | $3,801.89 |
- 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
- $1,905.46 / $2,398.83 / $3,801.89
| Professional | | $1,905.46 | $2,398.83 | $3,801.89 |