- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $4,265.80
| Facility | | $1,288.25 | $1,819.70 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,265.80
| Professional | | $2,570.40 | $3,235.94 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,365.16 / $5,128.61
| Professional | | $1,047.13 | $4,365.16 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $5,011.87
| Professional | | $2,238.72 | $2,818.38 | $5,011.87 |