- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.41 / $1,252.97 / $1,254.18
| Facility | | $1,097.41 | $1,252.97 | $1,254.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,097.41 / $1,410.95
| Professional | | $1,045.15 | $1,097.41 | $1,410.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.52 / $989.52 / $989.52
| Facility | | $989.52 | $989.52 | $989.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,232.59
| Facility | | $1,045.15 | $1,045.15 | $1,232.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.15 / $1,045.15 / $1,045.15
| Professional | | $1,045.15 | $1,045.15 | $1,045.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.16 / $1,106.16 / $1,106.16
| Facility | | $1,106.16 | $1,106.16 | $1,106.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.34 / $1,045.15 / $1,358.70
| Professional | | $1,003.34 | $1,045.15 | $1,358.70 |