- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.26 / $935.26 / $2,404.96
| Facility | | $935.26 | $935.26 | $2,404.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.26 / $935.26 / $1,255.92
| Professional | | $935.26 | $935.26 | $1,255.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.15 / $2,692.22 / $3,006.20
| Professional | | $2,011.15 | $2,692.22 | $3,006.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.12 / $1,535.12 / $2,253.63
| Professional | | $1,535.12 | $1,535.12 | $2,253.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.65 / $1,015.43 / $2,404.96
| Facility | | $801.65 | $1,015.43 | $2,404.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.41 / $1,603.31 / $2,672.18
| Professional | | $681.41 | $1,603.31 | $2,672.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $1,362.81 / $2,271.35
| Professional | | $561.16 | $1,362.81 | $2,271.35 |