- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.18 / $898.18 / $898.18
| Facility | | $898.18 | $898.18 | $898.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.18 / $1,094.38 / $1,589.45
| Professional | | $898.18 | $1,094.38 | $1,589.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,432.81 / $1,654.54 / $2,444.09
| Facility | | $1,432.81 | $1,654.54 | $2,444.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.81 / $1,207.81 / $2,140.14
| Professional | | $1,207.81 | $1,207.81 | $2,140.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.87 / $2,248.56 / $3,201.76
| Professional | | $2,232.87 | $2,248.56 | $3,201.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,386.81 / $2,444.09 / $2,444.09
| Professional | | $2,386.81 | $2,444.09 | $2,444.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.06 / $1,308.89 / $2,444.09
| Professional | | $1,102.06 | $1,308.89 | $2,444.09 |