- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $2,398.83
| Facility | | $933.25 | $933.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $1,584.89
| Professional | | $891.25 | $1,023.29 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $3,019.95
| Professional | | $1,737.80 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,905.46
| Professional | | $1,548.82 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $2,398.83
| Facility | | $794.33 | $1,023.29 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,584.89 / $2,691.53
| Professional | | $562.34 | $1,584.89 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,348.96 / $2,290.87
| Professional | | $562.34 | $1,348.96 | $2,290.87 |