- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,819.70 / $2,511.89
| Facility | | $1,047.13 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $912.01 / $1,348.96
| Professional | | $794.33 | $912.01 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,348.96 / $1,621.81
| Professional | | $724.44 | $1,348.96 | $1,621.81 |
- 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
- $794.33 / $1,122.02 / $1,621.81
| Professional | | $794.33 | $1,122.02 | $1,621.81 |