- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.26 / $935.26 / $935.26
| Facility | | $935.26 | $935.26 | $935.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.85 / $935.26 / $1,410.46
| Professional | | $753.85 | $935.26 | $1,410.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.18 / $1,145.08 / $1,873.59
| Professional | | $840.18 | $1,145.08 | $1,873.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.40 / $929.15 / $1,140.95
| Professional | | $719.40 | $929.15 | $1,140.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.51 / $1,392.22 / $1,558.38
| Professional | | $1,026.51 | $1,392.22 | $1,558.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.17 / $920.40 / $1,392.05
| Professional | | $715.17 | $920.40 | $1,392.05 |