- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.85 / $3,113.70 / $6,227.40
| Facility | | $1,556.85 | $3,113.70 | $6,227.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.85 / $2,490.96 / $2,490.96
| Professional | | $1,556.85 | $2,490.96 | $2,490.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,385.08 / $2,981.34
| Professional | | $2,385.08 | $2,385.08 | $2,981.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.85 / $2,490.96 / $2,490.96
| Facility | | $1,556.85 | $2,490.96 | $2,490.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.16 / $1,702.16 / $2,075.80
| Professional | | $1,702.16 | $1,702.16 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $871.84 / $1,245.48
| Professional | | $871.84 | $871.84 | $1,245.48 |