- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $1,513.56
| Facility | | $1,047.13 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $1,584.89
| Professional | | $691.83 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,318.26 / $1,584.89
| Professional | | $1,258.93 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $1,905.46
| Professional | | $1,380.38 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,258.93 / $1,905.46
| Professional | | $630.96 | $1,258.93 | $1,905.46 |