- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $734.82 / $734.82 / $734.82
| Facility | | $734.82 | $734.82 | $734.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.82 / $844.70 / $1,091.84
| Professional | | $734.82 | $844.70 | $1,091.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $1,108.41 / $2,158.52
| Facility | | $1,108.41 | $1,108.41 | $2,158.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.14 / $809.14 / $1,890.07
| Professional | | $809.14 | $809.14 | $1,890.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,971.95 / $1,985.84 / $2,827.66
| Professional | | $1,971.95 | $1,985.84 | $2,827.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.92 / $2,158.52 / $2,158.52
| Professional | | $2,107.92 | $2,158.52 | $2,158.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.38 / $1,076.85 / $2,158.52
| Professional | | $791.38 | $1,076.85 | $2,158.52 |