- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.62 / $915.62 / $1,430.65
| Facility | | $915.62 | $915.62 | $1,430.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.01 / $1,430.65 / $1,771.08
| Professional | | $866.01 | $1,430.65 | $1,771.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.09 / $1,266.09 / $1,266.09
| Facility | | $1,266.09 | $1,266.09 | $1,266.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.09 / $1,266.09 / $1,266.09
| Professional | | $1,266.09 | $1,266.09 | $1,266.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,018.60 / $1,018.60
| Facility | | $1,018.60 | $1,018.60 | $1,018.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $1,555.12
| Professional | | $743.58 | $743.58 | $1,555.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.16 / $815.11 / $1,253.19
| Professional | | $542.16 | $815.11 | $1,253.19 |