- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $1,548.82
| Facility | | $1,071.52 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,122.02 / $1,659.59
| Professional | | $707.95 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $1,621.81
| Professional | | $1,318.26 | $1,548.82 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,548.82 / $1,949.84
| Professional | | $1,445.44 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,318.26 / $1,949.84
| Professional | | $645.65 | $1,318.26 | $1,949.84 |