- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.20 / $1,067.83 / $1,370.47
| Facility | | $942.20 | $1,067.83 | $1,370.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.29 / $605.29 / $605.29
| Professional | | $605.29 | $605.29 | $605.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.47 / $1,370.47 / $1,370.47
| Professional | | $1,370.47 | $1,370.47 | $1,370.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.06 / $1,142.06 / $1,195.86
| Professional | | $1,142.06 | $1,142.06 | $1,195.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.27 / $1,370.47 / $1,598.88
| Professional | | $1,256.27 | $1,370.47 | $1,598.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.06 / $1,370.47 / $1,713.09
| Professional | | $1,142.06 | $1,370.47 | $1,713.09 |