- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.19 / $405.19 / $405.19
| Facility | | $405.19 | $405.19 | $405.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.19 / $454.43 / $757.78
| Professional | | $405.19 | $454.43 | $757.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.11 / $765.11 / $1,102.59
| Facility | | $765.11 | $765.11 | $1,102.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.53 / $558.53 / $965.47
| Professional | | $558.53 | $558.53 | $965.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.30 / $1,014.39 / $1,444.41
| Professional | | $1,007.30 | $1,014.39 | $1,444.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.76 / $1,102.59 / $1,102.59
| Professional | | $1,076.76 | $1,102.59 | $1,102.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.17 / $596.83 / $1,102.59
| Professional | | $497.17 | $596.83 | $1,102.59 |