- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,348.96 / $1,995.26
| Facility | | $1,318.26 | $1,348.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $1,348.96
| Professional | | $1,258.93 | $1,288.25 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,479.11 / $1,479.11
| Facility | | $1,318.26 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $7,079.46
| Professional | | $1,318.26 | $1,318.26 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $1,548.82
| Professional | | $1,288.25 | $1,380.38 | $1,548.82 |