- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $1,513.56
| Facility | | $1,174.90 | $1,479.11 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,202.26 / $1,479.11
| Professional | | $1,174.90 | $1,202.26 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,659.59
| Professional | | $1,348.96 | $1,348.96 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.88 / $12.88 / $12.88
| Facility | | $12.88 | $12.88 | $12.88 |