- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.41 / $1,181.40 / $1,516.24
| Facility | | $1,042.41 | $1,181.40 | $1,516.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.67 / $669.67 / $669.67
| Professional | | $669.67 | $669.67 | $669.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.24 / $1,516.24 / $1,516.24
| Professional | | $1,516.24 | $1,516.24 | $1,516.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,323.07 / $1,579.41
| Professional | | $1,263.53 | $1,323.07 | $1,579.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.88 / $1,516.24 / $1,768.94
| Professional | | $1,389.88 | $1,516.24 | $1,768.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.24 / $1,516.24 / $1,895.30
| Professional | | $1,516.24 | $1,516.24 | $1,895.30 |