- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.69 / $585.69 / $585.69
| Facility | | $585.69 | $585.69 | $585.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.69 / $783.36 / $1,033.30
| Professional | | $585.69 | $783.36 | $1,033.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $996.07 / $1,212.63 / $1,720.43
| Facility | | $996.07 | $1,212.63 | $1,720.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.22 / $885.22 / $1,506.47
| Professional | | $885.22 | $885.22 | $1,506.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.74 / $1,582.80 / $2,253.76
| Professional | | $1,571.74 | $1,582.80 | $2,253.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.10 / $1,720.43 / $1,720.43
| Professional | | $1,680.10 | $1,720.43 | $1,720.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.75 / $858.30 / $1,720.43
| Professional | | $775.75 | $858.30 | $1,720.43 |