- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $7,762.47 / $14,125.38
| Facility | | $2,238.72 | $7,762.47 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,570.40 / $14,125.38
| Professional | | $1,348.96 | $2,570.40 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,128.61 / $10,232.93
| Facility | | $2,238.72 | $5,128.61 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $891.25 / $2,570.40
| Professional | | $60.26 | $891.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |