- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $768.80 / $837.84 / $1,005.41
| Facility | | $768.80 | $837.84 | $1,005.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.80 / $935.59 / $1,350.40
| Professional | | $768.80 | $935.59 | $1,350.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,122.47
| Facility | | $1,122.47 | $1,122.47 | $1,122.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.57 / $1,122.47 / $1,156.14
| Professional | | $341.57 | $1,122.47 | $1,156.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.50 / $1,174.90 / $1,307.88
| Facility | | $661.50 | $1,174.90 | $1,307.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.75 / $1,632.70 / $1,632.70
| Professional | | $1,165.75 | $1,632.70 | $1,632.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.91 / $1,153.21 / $1,441.52
| Professional | | $864.91 | $1,153.21 | $1,441.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.49 / $865.92 / $1,396.53
| Professional | | $681.49 | $865.92 | $1,396.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.52 / $1,441.52 / $1,441.52
| Professional | | $1,441.52 | $1,441.52 | $1,441.52 |