- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.55 / $785.55 / $785.55
| Facility | | $785.55 | $785.55 | $785.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.55 / $954.62 / $1,389.81
| Professional | | $785.55 | $954.62 | $1,389.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.54 / $1,222.54 / $2,137.66
| Facility | | $1,222.54 | $1,222.54 | $2,137.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.45 / $892.45 / $2,539.13
| Professional | | $892.45 | $892.45 | $2,539.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,966.65 / $2,800.33
| Professional | | $1,952.91 | $1,966.65 | $2,800.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.56 / $2,137.66 / $2,137.66
| Professional | | $2,087.56 | $2,137.66 | $2,137.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.37 / $2,608.67 / $3,130.40
| Facility | | $2,217.37 | $2,608.67 | $3,130.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.87 / $1,124.41 / $1,962.49
| Professional | | $963.87 | $1,124.41 | $1,962.49 |