- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $7,762.47
| Facility | | $7,762.47 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $1,445.44
| Professional | | $676.08 | $812.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,071.52 / $1,778.28
| Professional | | $676.08 | $1,071.52 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,230.27
| Facility | | $977.24 | $977.24 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $977.24 / $1,778.28
| Professional | | $549.54 | $977.24 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $2,137.96
| Professional | | $831.76 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $7,762.47
| Facility | | $7,762.47 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $2,187.76
| Professional | | $691.83 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,659.59
| Professional | | $724.44 | $1,047.13 | $1,659.59 |