- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $828.45 / $828.45 / $828.45
| Facility | | $828.45 | $828.45 | $828.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.45 / $1,161.91 / $1,461.58
| Professional | | $828.45 | $1,161.91 | $1,461.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.41 / $1,638.80 / $2,433.53
| Facility | | $1,476.41 | $1,638.80 | $2,433.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $2,937.00
| Professional | | $1,196.32 | $1,196.32 | $2,937.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.19 / $2,238.85 / $3,187.92
| Professional | | $2,223.19 | $2,238.85 | $3,187.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,316.27 / $2,433.53 / $2,433.53
| Professional | | $2,316.27 | $2,433.53 | $2,433.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.29 / $1,203.23 / $1,376.73
| Facility | | $1,097.29 | $1,203.23 | $1,376.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.29 / $1,262.95 / $2,234.09
| Professional | | $1,097.29 | $1,262.95 | $2,234.09 |