- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $730.02 / $730.02 / $730.02
| Facility | | $730.02 | $730.02 | $730.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.02 / $929.15 / $1,202.46
| Professional | | $730.02 | $929.15 | $1,202.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,304.10 / $2,144.42
| Facility | | $1,304.10 | $1,304.10 | $2,144.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $952.00 / $1,877.73
| Professional | | $952.00 | $952.00 | $1,877.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.08 / $1,972.87 / $2,809.19
| Professional | | $1,959.08 | $1,972.87 | $2,809.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.16 / $2,144.42 / $2,144.42
| Professional | | $2,094.16 | $2,144.42 | $2,144.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.93 / $1,069.82 / $2,144.42
| Professional | | $906.93 | $1,069.82 | $2,144.42 |