- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.93 / $1,220.52 / $1,566.44
| Facility | | $1,076.93 | $1,220.52 | $1,566.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.85 / $691.85 / $691.85
| Professional | | $691.85 | $691.85 | $691.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.44 / $1,566.44 / $1,566.44
| Professional | | $1,566.44 | $1,566.44 | $1,566.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.19 / $1,475.07 / $1,631.71
| Professional | | $1,230.19 | $1,475.07 | $1,631.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.91 / $1,566.44 / $1,827.52
| Professional | | $1,435.91 | $1,566.44 | $1,827.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,566.44 / $1,958.06
| Professional | | $1,305.36 | $1,566.44 | $1,958.06 |