- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.08 / $1,047.08 / $1,047.08
| Facility | | $1,047.08 | $1,047.08 | $1,047.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.10 / $1,047.08 / $1,109.91
| Professional | | $952.10 | $1,047.08 | $1,109.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.11 / $777.53 / $1,358.90
| Professional | | $508.11 | $777.53 | $1,358.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.14 / $2,537.59 / $4,662.95
| Professional | | $1,064.14 | $2,537.59 | $4,662.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.94 / $2,270.63 / $2,270.63
| Professional | | $1,062.94 | $2,270.63 | $2,270.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.35 / $2,053.69 / $4,163.56
| Professional | | $441.35 | $2,053.69 | $4,163.56 |