- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.16 / $983.72 / $2,595.59
| Facility | | $948.16 | $983.72 | $2,595.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.16 / $983.72 / $1,007.42
| Professional | | $948.16 | $983.72 | $1,007.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Facility | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Professional | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,185.20
| Professional | | $1,185.20 | $1,185.20 | $1,185.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Professional | | $1,046.93 | $1,046.93 | $1,046.93 |