- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.44 / $2,782.73 / $5,897.05
| Facility | | $908.44 | $2,782.73 | $5,897.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,214.63
| Professional | | $1,214.63 | $1,214.63 | $1,214.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Facility | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.31 / $1,214.63 / $1,214.63
| Professional | | $1,105.31 | $1,214.63 | $1,214.63 |