- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.50 / $517.50 / $1,700.00
| Facility | | $517.50 | $517.50 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.50 / $517.50 / $559.26
| Professional | | $517.50 | $517.50 | $559.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,413.07 / $1,413.07 / $1,413.08
| Facility | | $1,413.07 | $1,413.07 | $1,413.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.07 / $1,256.07 / $1,256.07
| Professional | | $1,256.07 | $1,256.07 | $1,256.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.84 / $2,120.84 / $2,120.84
| Professional | | $2,120.84 | $2,120.84 | $2,120.84 |