- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,417.80 / $7,838.38 / $14,860.56
| Facility | | $1,417.80 | $7,838.38 | $14,860.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.80 / $1,474.90 / $1,741.92
| Professional | | $1,417.80 | $1,474.90 | $1,741.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $2,823.68
| Professional | | $60.00 | $85.00 | $2,823.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $4,262.00 / $17,636.00
| Facility | | $3,085.00 | $4,262.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,335.52 / $2,866.33 / $4,193.32
| Professional | | $2,335.52 | $2,866.33 | $4,193.32 |