- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.26 / $927.26 / $1,448.84
| Facility | | $927.26 | $927.26 | $1,448.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.26 / $1,448.84 / $1,847.88
| Professional | | $927.26 | $1,448.84 | $1,847.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.21 / $1,282.21 / $1,282.21
| Facility | | $1,282.21 | $1,282.21 | $1,282.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.21 / $1,282.21 / $1,282.21
| Professional | | $1,282.21 | $1,282.21 | $1,282.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.14 / $1,427.14 / $1,427.14
| Facility | | $1,427.14 | $1,427.14 | $1,427.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.81 / $1,041.81 / $1,427.14
| Professional | | $1,041.81 | $1,041.81 | $1,427.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.32 / $825.47 / $1,272.03
| Professional | | $550.32 | $825.47 | $1,272.03 |