- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.31 / $5,371.96 / $16,482.15
| Facility | | $1,730.31 | $5,371.96 | $16,482.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.31 / $1,730.31 / $4,049.70
| Professional | | $1,730.31 | $1,730.31 | $4,049.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,666.78 / $1,666.78 / $1,666.78
| Facility | | $1,666.78 | $1,666.78 | $1,666.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.60 / $1,834.14 / $2,595.48
| Professional | | $1,723.60 | $1,834.14 | $2,595.48 |