- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,137.96 / $2,818.38
| Facility | | $1,348.96 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $6,025.60
| Professional | | $1,548.82 | $1,737.80 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,570.40 / $2,951.21
| Professional | | $1,412.54 | $2,570.40 | $2,951.21 |
- 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
- $1,548.82 / $1,995.26 / $3,162.28
| Professional | | $1,548.82 | $1,995.26 | $3,162.28 |