- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.34 / $708.34 / $708.34
| Facility | | $708.34 | $708.34 | $708.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.09 / $708.34 / $761.85
| Professional | | $702.09 | $708.34 | $761.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,062.44 / $2,166.81 / $2,600.17
| Facility | | $1,062.44 | $2,166.81 | $2,600.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.95 / $1,144.17 / $1,961.44
| Professional | | $938.95 | $1,144.17 | $1,961.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $902.63 / $902.63 / $1,915.46
| Facility | | $902.63 | $902.63 | $1,915.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.92 / $902.63 / $7,789.51
| Professional | | $658.92 | $902.63 | $7,789.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.66 / $1,006.71 / $1,201.09
| Professional | | $720.66 | $1,006.71 | $1,201.09 |