- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,185.20
| Facility | | $1,185.20 | $1,185.20 | $1,185.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.72 / $983.72 / $1,007.42
| Professional | | $983.72 | $983.72 | $1,007.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.50 / $1,066.50 / $1,333.13
| Professional | | $1,066.50 | $1,066.50 | $1,333.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,306.94 / $1,761.68
| Facility | | $1,185.20 | $1,306.94 | $1,761.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,303.72
| Professional | | $1,185.20 | $1,185.20 | $1,303.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,256.09 / $1,306.94 / $1,460.37
| Facility | | $1,256.09 | $1,306.94 | $1,460.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.18 / $1,256.09 / $2,732.49
| Professional | | $1,186.18 | $1,256.09 | $2,732.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,303.72
| Professional | | $1,185.20 | $1,185.20 | $1,303.72 |