- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $778.65 / $778.65 / $778.65
| Facility | | $778.65 | $778.65 | $778.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.65 / $1,052.11 / $1,373.73
| Professional | | $778.65 | $1,052.11 | $1,373.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,431.54 / $1,499.97 / $2,287.23
| Facility | | $1,431.54 | $1,499.97 | $2,287.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.98 / $1,094.98 / $2,002.78
| Professional | | $1,094.98 | $1,094.98 | $2,002.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.56 / $2,104.25 / $2,996.27
| Professional | | $2,089.56 | $2,104.25 | $2,996.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.62 / $2,287.23 / $2,287.23
| Professional | | $2,233.62 | $2,287.23 | $2,287.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.30 / $1,141.07 / $2,287.23
| Professional | | $1,030.30 | $1,141.07 | $2,287.23 |