- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,922.35 / $1,922.35 / $1,922.35
| Facility | | $1,922.35 | $1,922.35 | $1,922.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.73 / $982.11 / $1,540.11
| Professional | | $697.73 | $982.11 | $1,540.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.21 / $1,477.66 / $1,978.64
| Professional | | $754.21 | $1,477.66 | $1,978.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.79 / $1,152.32 / $2,560.67
| Professional | | $839.79 | $1,152.32 | $2,560.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.56 / $1,338.41 / $2,039.82
| Professional | | $1,077.56 | $1,338.41 | $2,039.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.52 / $1,009.18 / $2,344.80
| Professional | | $735.52 | $1,009.18 | $2,344.80 |