- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.16 / $774.16 / $774.16
| Facility | | $774.16 | $774.16 | $774.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.16 / $989.62 / $1,251.42
| Professional | | $774.16 | $989.62 | $1,251.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.55 / $1,300.55 / $2,274.06
| Facility | | $1,300.55 | $1,300.55 | $2,274.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.40 / $949.40 / $2,701.13
| Professional | | $949.40 | $949.40 | $2,701.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.51 / $2,092.14 / $2,979.02
| Professional | | $2,077.51 | $2,092.14 | $2,979.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.48 / $2,274.06 / $2,274.06
| Professional | | $2,164.48 | $2,274.06 | $2,274.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.83 / $1,134.50 / $2,274.06
| Professional | | $942.83 | $1,134.50 | $2,274.06 |