- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.64 / $604.64 / $604.64
| Facility | | $604.64 | $604.64 | $604.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.64 / $772.76 / $1,128.03
| Professional | | $604.64 | $772.76 | $1,128.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,260.83 / $1,645.34
| Facility | | $1,260.83 | $1,260.83 | $1,645.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.41 / $920.41 / $1,440.72
| Professional | | $920.41 | $920.41 | $1,440.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.15 / $1,513.71 / $2,155.40
| Professional | | $1,503.15 | $1,513.71 | $2,155.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.72 / $1,606.78 / $1,645.34
| Professional | | $1,440.72 | $1,606.78 | $1,645.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.94 / $887.11 / $1,510.51
| Professional | | $758.94 | $887.11 | $1,510.51 |