- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $884.47 / $985.55 / $5,992.14
| Facility | | $884.47 | $985.55 | $5,992.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.55 / $985.55 / $1,010.82
| Professional | | $985.55 | $985.55 | $1,010.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $1,727.88
| Professional | | $1,263.53 | $1,263.53 | $1,727.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $841.94 / $2,562.42 / $7,204.36
| Facility | | $841.94 | $2,562.42 | $7,204.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $972.92 / $1,263.53 / $1,351.98
| Facility | | $972.92 | $1,263.53 | $1,351.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $758.12 / $1,263.53
| Professional | | $530.67 | $758.12 | $1,263.53 |