- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.29 / $840.29 / $840.29
| Facility | | $840.29 | $840.29 | $840.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.86 / $840.29 / $1,086.28
| Professional | | $791.86 | $840.29 | $1,086.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.43 / $1,459.21 / $1,963.10
| Facility | | $1,202.43 | $1,459.21 | $1,963.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.64 / $1,090.64 / $1,090.64
| Professional | | $1,090.64 | $1,090.64 | $1,090.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.59 / $2,155.28 / $4,232.47
| Professional | | $1,271.59 | $2,155.28 | $4,232.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.45 / $1,308.77 / $1,374.21
| Professional | | $1,112.45 | $1,308.77 | $1,374.21 |