- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $2,454.71
| Facility | | $1,348.96 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $1,698.24
| Professional | | $1,047.13 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,698.24 / $2,137.96
| Professional | | $933.25 | $1,698.24 | $2,137.96 |
- 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
- $1,047.13 / $1,380.38 / $2,187.76
| Professional | | $1,047.13 | $1,380.38 | $2,187.76 |