- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $865.01 / $865.01 / $865.01
| Facility | | $865.01 | $865.01 | $865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.01 / $1,051.17 / $1,530.39
| Professional | | $865.01 | $1,051.17 | $1,530.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.19 / $1,346.19 / $2,353.86
| Facility | | $1,346.19 | $1,346.19 | $2,353.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.72 / $982.72 / $2,061.12
| Professional | | $982.72 | $982.72 | $2,061.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.42 / $2,165.55 / $3,083.56
| Professional | | $2,150.42 | $2,165.55 | $3,083.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.69 / $2,353.86 / $2,353.86
| Professional | | $2,298.69 | $2,353.86 | $2,353.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.35 / $1,174.31 / $2,160.96
| Professional | | $1,061.35 | $1,174.31 | $2,160.96 |