- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.79 / $1,180.30 / $1,186.75
| Facility | | $950.79 | $1,180.30 | $1,186.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.58 / $1,180.30 / $1,630.56
| Professional | | $983.58 | $1,180.30 | $1,630.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,293.24 / $1,293.24 / $1,293.24
| Facility | | $1,293.24 | $1,293.24 | $1,293.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.30 / $1,491.30 / $1,491.30
| Professional | | $1,491.30 | $1,491.30 | $1,491.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.24 / $2,143.19 / $2,447.40
| Professional | | $1,500.24 | $2,143.19 | $2,447.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.52 / $200.72 / $1,635.20
| Professional | | $163.52 | $200.72 | $1,635.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.52 / $865.75 / $1,442.91
| Facility | | $106.52 | $865.75 | $1,442.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.30 / $1,097.30 / $1,774.55
| Professional | | $868.30 | $1,097.30 | $1,774.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.50 / $1,467.50 / $1,467.50
| Professional | | $1,467.50 | $1,467.50 | $1,467.50 |