- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.25 / $1,515.70 / $9,215.45
| Facility | | $1,360.25 | $1,515.70 | $9,215.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.70 / $1,515.70 / $1,690.59
| Professional | | $1,515.70 | $1,515.70 | $1,690.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.21 / $2,040.37 / $2,681.63
| Professional | | $1,943.21 | $2,040.37 | $2,681.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,531.60 / $4,787.10 / $11,079.83
| Facility | | $3,531.60 | $4,787.10 | $11,079.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,515.70 / $1,943.21 / $2,455.42
| Facility | | $1,515.70 | $1,943.21 | $2,455.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $1,943.21
| Professional | | $816.15 | $1,165.93 | $1,943.21 |