- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.13 / $956.13 / $1,931.80
| Facility | | $956.13 | $956.13 | $1,931.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.36 / $992.91 / $1,074.25
| Professional | | $919.36 | $992.91 | $1,074.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.12 / $1,728.96 / $1,931.80
| Facility | | $1,526.12 | $1,728.96 | $1,931.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.40 / $1,148.64 / $1,585.12
| Professional | | $942.40 | $1,148.64 | $1,585.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.85 / $2,124.98 / $2,897.70
| Facility | | $1,448.85 | $2,124.98 | $2,897.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.03 / $2,124.98 / $2,607.92
| Professional | | $1,642.03 | $2,124.98 | $2,607.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.09 / $1,207.09 / $1,931.80
| Facility | | $1,207.09 | $1,207.09 | $1,931.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $1,207.09 / $1,981.66
| Professional | | $881.18 | $1,207.09 | $1,981.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.50 / $963.76 / $1,423.15
| Professional | | $642.50 | $963.76 | $1,423.15 |