- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $846.27
| Facility | | $846.27 | $846.27 | $846.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.12 / $846.27 / $846.27
| Professional | | $836.12 | $846.27 | $846.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.83 / $1,312.00 / $2,708.00
| Professional | | $1,057.83 | $1,312.00 | $2,708.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,692.32 / $1,692.32 / $1,692.32
| Facility | | $1,692.32 | $1,692.32 | $1,692.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.43 / $1,376.24 / $1,819.55
| Professional | | $399.43 | $1,376.24 | $1,819.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $355.43 / $846.27
| Professional | | $355.43 | $355.43 | $846.27 |