- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $834.53 / $834.53 / $834.53
| Facility | | $834.53 | $834.53 | $834.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.53 / $1,055.26 / $1,324.67
| Professional | | $834.53 | $1,055.26 | $1,324.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.14 / $1,618.14 / $2,451.42
| Facility | | $1,618.14 | $1,618.14 | $2,451.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.24 / $1,181.24 / $2,146.55
| Professional | | $1,181.24 | $1,181.24 | $2,146.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.54 / $2,255.32 / $3,211.37
| Professional | | $2,239.54 | $2,255.32 | $3,211.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.55 / $2,393.96 / $2,451.42
| Professional | | $2,146.55 | $2,393.96 | $2,451.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.10 / $1,222.99 / $2,451.42
| Professional | | $999.10 | $1,222.99 | $2,451.42 |