- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $838.45 / $950.24 / $1,117.93
| Facility | | $838.45 | $950.24 | $1,117.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.45 / $1,051.66 / $1,361.67
| Professional | | $838.45 | $1,051.66 | $1,361.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,077.57 / $1,077.57
| Professional | | $1,077.57 | $1,077.57 | $1,077.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,077.57 / $1,627.01
| Professional | | $1,077.57 | $1,077.57 | $1,627.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.90 / $1,580.43 / $3,529.26
| Professional | | $1,229.90 | $1,580.43 | $3,529.26 |