- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $698.17 / $791.26 / $1,015.52
| Facility | | $698.17 | $791.26 | $1,015.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.52 / $448.52 / $448.52
| Professional | | $448.52 | $448.52 | $448.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.52 / $1,015.52 / $1,015.52
| Professional | | $1,015.52 | $1,015.52 | $1,015.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.54 / $956.29 / $1,057.83
| Professional | | $797.54 | $956.29 | $1,057.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.90 / $1,015.52 / $1,184.78
| Professional | | $930.90 | $1,015.52 | $1,184.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $1,015.52 / $1,269.41
| Professional | | $846.27 | $1,015.52 | $1,269.41 |