- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.13 / $1,400.00 / $1,700.00
| Facility | | $941.13 | $1,400.00 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.13 / $1,038.73 / $1,385.87
| Professional | | $941.13 | $1,038.73 | $1,385.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $995.63 / $1,098.73 / $1,197.08
| Facility | | $995.63 | $1,098.73 | $1,197.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.85 / $1,064.08 / $1,064.08
| Professional | | $545.85 | $1,064.08 | $1,064.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.09 / $1,095.42 / $1,418.77
| Professional | | $697.09 | $1,095.42 | $1,418.77 |