- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.48 / $837.48 / $837.48
| Facility | | $837.48 | $837.48 | $837.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.98 / $891.84 / $1,217.43
| Professional | | $821.98 | $891.84 | $1,217.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.72 / $1,408.48 / $2,278.94
| Facility | | $1,072.72 | $1,408.48 | $2,278.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.19 / $1,028.19 / $1,995.52
| Professional | | $1,028.19 | $1,028.19 | $1,995.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.98 / $2,096.62 / $2,985.41
| Professional | | $2,081.98 | $2,096.62 | $2,985.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.52 / $2,278.94 / $2,278.94
| Professional | | $1,995.52 | $2,278.94 | $2,278.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.28 / $1,198.84 / $2,278.94
| Professional | | $918.28 | $1,198.84 | $2,278.94 |