- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.37 / $868.37 / $868.37
| Facility | | $868.37 | $868.37 | $868.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.51 / $805.72 / $870.18
| Professional | | $777.51 | $805.72 | $870.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.65 / $1,786.65 / $2,044.11
| Facility | | $1,384.65 | $1,786.65 | $2,044.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.13 / $1,442.58 / $1,442.58
| Professional | | $1,140.13 | $1,442.58 | $1,442.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.07 / $1,022.07 / $1,022.07
| Facility | | $1,022.07 | $1,022.07 | $1,022.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.76 / $868.76 / $1,022.07
| Professional | | $868.76 | $868.76 | $1,022.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,161.32 / $1,161.32 / $1,161.32
| Facility | | $1,161.32 | $1,161.32 | $1,161.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.32 / $1,161.32 / $1,643.72
| Professional | | $1,161.32 | $1,161.32 | $1,643.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.23 / $891.34 / $1,257.46
| Professional | | $680.23 | $891.34 | $1,257.46 |