- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $2,511.89
| Facility | | $1,202.26 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,148.15 / $1,621.81
| Professional | | $1,023.29 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,445.44 / $1,819.70
| Professional | | $954.99 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $14,454.40
| Facility | | $2,187.76 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $1,995.26
| Professional | | $954.99 | $1,258.93 | $1,995.26 |