- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.48 / $676.48 / $676.48
| Facility | | $676.48 | $676.48 | $676.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.48 / $822.07 / $1,196.83
| Professional | | $676.48 | $822.07 | $1,196.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.56 / $1,329.56 / $1,840.86
| Facility | | $1,329.56 | $1,329.56 | $1,840.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.58 / $970.58 / $2,186.63
| Professional | | $970.58 | $970.58 | $2,186.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.75 / $1,693.59 / $2,411.53
| Professional | | $1,681.75 | $1,693.59 | $2,411.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.15 / $1,840.86 / $1,840.86
| Professional | | $1,752.15 | $1,840.86 | $1,840.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.04 / $1,011.27 / $1,840.86
| Professional | | $830.04 | $1,011.27 | $1,840.86 |