- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $873.95 / $873.95 / $873.95
| Facility | | $873.95 | $873.95 | $873.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.51 / $859.54 / $879.64
| Professional | | $782.51 | $859.54 | $879.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.55 / $1,798.13 / $2,057.23
| Facility | | $1,393.55 | $1,798.13 | $2,057.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.36 / $1,002.36 / $1,050.24
| Professional | | $1,002.36 | $1,002.36 | $1,050.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.78 / $1,191.78 / $1,191.78
| Facility | | $1,191.78 | $1,191.78 | $1,191.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.00 / $870.00 / $1,191.78
| Professional | | $870.00 | $870.00 | $1,191.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,168.78 / $1,168.78 / $1,168.78
| Facility | | $1,168.78 | $1,168.78 | $1,168.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.78 / $1,168.78 / $1,654.28
| Professional | | $1,168.78 | $1,168.78 | $1,654.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.20 / $1,368.20 / $1,368.20
| Professional | | $1,368.20 | $1,368.20 | $1,368.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.17 / $897.07 / $1,495.12
| Professional | | $688.17 | $897.07 | $1,495.12 |