- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.16 / $948.16 / $1,185.20
| Facility | | $948.16 | $948.16 | $1,185.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.16 / $948.16 / $983.72
| Professional | | $948.16 | $948.16 | $983.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.50 / $1,066.50 / $1,333.13
| Professional | | $1,066.50 | $1,066.50 | $1,333.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.16 / $1,185.20 / $1,611.87
| Facility | | $948.16 | $1,185.20 | $1,611.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,287.19
| Professional | | $1,185.20 | $1,185.20 | $1,287.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.42 / $1,185.20 / $1,287.19
| Professional | | $1,007.42 | $1,185.20 | $1,287.19 |