- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.04 / $1,437.11 / $1,844.42
| Facility | | $1,268.04 | $1,437.11 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.62 / $814.62 / $814.62
| Professional | | $814.62 | $814.62 | $814.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.42 / $1,844.42 / $1,844.42
| Professional | | $1,844.42 | $1,844.42 | $1,844.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.74 / $362.74 / $362.74
| Professional | | $362.74 | $362.74 | $362.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.72 / $1,844.42 / $2,151.83
| Professional | | $1,690.72 | $1,844.42 | $2,151.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.02 / $1,844.42 / $2,305.53
| Professional | | $1,537.02 | $1,844.42 | $2,305.53 |