- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.76 / $1,219.19 / $1,564.74
| Facility | | $1,075.76 | $1,219.19 | $1,564.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.74 / $1,564.74 / $1,564.74
| Professional | | $1,564.74 | $1,564.74 | $1,564.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.29 / $1,547.14 / $1,711.44
| Professional | | $1,290.29 | $1,547.14 | $1,711.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.35 / $1,564.74 / $1,825.53
| Professional | | $1,434.35 | $1,564.74 | $1,825.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.98 / $1,564.74 / $1,676.97
| Professional | | $1,117.98 | $1,564.74 | $1,676.97 |