- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.41 / $938.45 / $950.34
| Facility | | $826.41 | $938.45 | $950.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.41 / $933.53 / $1,086.28
| Professional | | $826.41 | $933.53 | $1,086.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.02 / $1,047.02 / $1,151.72
| Facility | | $1,047.02 | $1,047.02 | $1,151.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.89 / $1,177.89 / $1,177.89
| Professional | | $1,177.89 | $1,177.89 | $1,177.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.69 / $1,271.69 / $1,271.69
| Facility | | $1,271.69 | $1,271.69 | $1,271.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.14 / $1,308.77 / $1,618.51
| Professional | | $869.14 | $1,308.77 | $1,618.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.33 / $1,308.77 / $1,668.96
| Professional | | $1,243.33 | $1,308.77 | $1,668.96 |