- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $2,691.53
| Facility | | $1,348.96 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $2,187.76
| Professional | | $1,380.38 | $1,548.82 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,290.87 / $2,630.27
| Professional | | $1,258.93 | $2,290.87 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $11,748.98
| Facility | | $1,548.82 | $4,073.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,818.38
| Professional | | $1,380.38 | $1,819.70 | $2,818.38 |