- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.73 / $830.73 / $830.73
| Facility | | $830.73 | $830.73 | $830.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.73 / $1,045.32 / $1,470.49
| Professional | | $830.73 | $1,045.32 | $1,470.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,325.42 / $1,747.16 / $2,260.57
| Facility | | $1,325.42 | $1,747.16 | $2,260.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,275.43 / $1,979.43
| Professional | | $1,275.43 | $1,275.43 | $1,979.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.19 / $2,079.71 / $2,961.35
| Professional | | $2,065.19 | $2,079.71 | $2,961.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.59 / $2,260.57 / $2,260.57
| Professional | | $2,207.59 | $2,260.57 | $2,260.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.30 / $1,208.35 / $2,260.57
| Professional | | $1,019.30 | $1,208.35 | $2,260.57 |