- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $874.10 / $874.10 / $874.10
| Facility | | $874.10 | $874.10 | $874.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.10 / $1,062.21 / $1,516.86
| Professional | | $874.10 | $1,062.21 | $1,516.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,355.48 / $1,486.28 / $2,378.58
| Facility | | $1,355.48 | $1,486.28 | $2,378.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,084.98 / $2,082.77
| Professional | | $1,084.98 | $1,084.98 | $2,082.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,173.01 / $2,188.29 / $3,115.94
| Professional | | $2,173.01 | $2,188.29 | $3,115.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,322.83 / $2,378.58 / $2,378.58
| Professional | | $2,322.83 | $2,378.58 | $2,378.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.89 / $1,428.89 / $1,428.89
| Facility | | $1,428.89 | $1,428.89 | $1,428.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.51 / $1,419.09 / $2,378.58
| Professional | | $1,072.51 | $1,419.09 | $2,378.58 |