- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.75 / $845.05 / $967.21
| Facility | | $785.75 | $845.05 | $967.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.75 / $942.28 / $1,369.83
| Professional | | $785.75 | $942.28 | $1,369.83 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $829.04 / $1,381.73 / $1,840.46
| Professional | | $829.04 | $1,381.73 | $1,840.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.36 / $1,472.36 / $1,472.36
| Professional | | $1,472.36 | $1,472.36 | $1,472.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.02 / $918.18 / $1,229.49
| Professional | | $816.02 | $918.18 | $1,229.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.58 / $1,442.58 / $1,840.46
| Professional | | $1,442.58 | $1,442.58 | $1,840.46 |