- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.10 / $776.10 / $776.10
| Facility | | $776.10 | $776.10 | $776.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.10 / $943.12 / $1,373.10
| Professional | | $776.10 | $943.12 | $1,373.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $2,111.91
| Facility | | $1,207.83 | $1,207.83 | $2,111.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $881.72 / $1,849.26
| Professional | | $881.72 | $881.72 | $1,849.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.38 / $1,942.96 / $2,766.60
| Professional | | $1,929.38 | $1,942.96 | $2,766.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.41 / $2,111.91 / $2,111.91
| Professional | | $2,062.41 | $2,111.91 | $2,111.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.55 / $1,055.55 / $1,055.55
| Facility | | $1,055.55 | $1,055.55 | $1,055.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.27 / $1,110.88 / $2,111.91
| Professional | | $952.27 | $1,110.88 | $2,111.91 |