- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,140.59 / $1,140.59 / $1,140.59
| Facility | | $1,140.59 | $1,140.59 | $1,140.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,201.00 / $1,201.00
| Professional | | $1,201.00 | $1,201.00 | $1,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.22 / $362.47 / $436.61
| Professional | | $326.22 | $362.47 | $436.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.31 / $2,149.55 / $2,386.46
| Facility | | $1,788.31 | $2,149.55 | $2,386.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.85 / $1,201.00 / $1,273.06
| Facility | | $1,020.85 | $1,201.00 | $1,273.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.50 / $1,235.65 / $2,138.63
| Facility | | $950.50 | $1,235.65 | $2,138.63 |