- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $871.26 / $871.26 / $871.26
| Facility | | $871.26 | $871.26 | $871.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.13 / $871.26 / $1,007.98
| Professional | | $836.13 | $871.26 | $1,007.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.60 / $1,142.90 / $1,885.79
| Professional | | $1,028.60 | $1,142.90 | $1,885.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.50 / $2,716.04 / $4,323.60
| Professional | | $1,078.50 | $2,716.04 | $4,323.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.87 / $2,208.06 / $2,208.06
| Professional | | $1,018.87 | $2,208.06 | $2,208.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.83 / $2,051.29 / $2,772.01
| Professional | | $741.83 | $2,051.29 | $2,772.01 |