- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.21 / $854.21 / $854.21
| Facility | | $854.21 | $854.21 | $854.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.01 / $981.94 / $1,130.27
| Professional | | $854.01 | $981.94 | $1,130.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,277.46 / $2,509.19
| Facility | | $1,277.46 | $1,277.46 | $2,509.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.55 / $932.55 / $2,197.13
| Professional | | $932.55 | $932.55 | $2,197.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,292.33 / $2,308.44 / $3,287.04
| Professional | | $2,292.33 | $2,308.44 | $3,287.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.38 / $2,509.19 / $2,509.19
| Professional | | $2,450.38 | $2,509.19 | $2,509.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.44 / $1,251.80 / $2,303.55
| Professional | | $880.44 | $1,251.80 | $2,303.55 |