- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.74 / $974.74 / $974.74
| Facility | | $974.74 | $974.74 | $974.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.30 / $974.74 / $1,136.01
| Professional | | $801.30 | $974.74 | $1,136.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.74 / $961.80 / $1,251.70
| Professional | | $640.74 | $961.80 | $1,251.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.43 / $204.82 / $2,077.11
| Facility | | $104.43 | $204.82 | $2,077.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.41 / $189.06 / $2,492.53
| Professional | | $102.41 | $189.06 | $2,492.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $1,223.23 / $1,445.28
| Professional | | $124.05 | $1,223.23 | $1,445.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.41 / $672.13 / $1,003.53
| Professional | | $492.41 | $672.13 | $1,003.53 |