- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,102.27 / $1,249.24 / $1,603.31
| Facility | | $1,102.27 | $1,249.24 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.13 / $708.13 / $708.13
| Professional | | $708.13 | $708.13 | $708.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.31 / $1,603.31 / $1,603.31
| Professional | | $1,603.31 | $1,603.31 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,399.05 / $1,670.11
| Professional | | $1,336.09 | $1,399.05 | $1,670.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.70 / $1,603.31 / $1,870.53
| Professional | | $1,469.70 | $1,603.31 | $1,870.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.09 / $1,603.31 / $2,004.14
| Professional | | $1,336.09 | $1,603.31 | $2,004.14 |