- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $792.21 / $792.21 / $1,262.58
| Facility | | $792.21 | $792.21 | $1,262.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.65 / $903.62 / $1,262.58
| Professional | | $743.65 | $903.62 | $1,262.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.46 / $1,095.46 / $1,095.46
| Facility | | $1,095.46 | $1,095.46 | $1,095.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.46 / $1,095.46 / $1,095.46
| Professional | | $1,095.46 | $1,095.46 | $1,095.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.46 / $907.46 / $907.46
| Facility | | $907.46 | $907.46 | $907.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.45 / $662.45 / $907.46
| Professional | | $662.45 | $662.45 | $907.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.75 / $657.65 / $1,052.74
| Professional | | $417.75 | $657.65 | $1,052.74 |