- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,301.55 / $3,301.55 / $3,458.76
| Facility | | $3,301.55 | $3,301.55 | $3,458.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.24 / $769.02 / $1,232.86
| Professional | | $726.24 | $769.02 | $1,232.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.26 / $1,026.10 / $1,647.74
| Professional | | $886.26 | $1,026.10 | $1,647.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.30 / $1,165.13 / $1,669.25
| Professional | | $914.30 | $1,165.13 | $1,669.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.54 / $1,125.04 / $1,725.88
| Professional | | $873.54 | $1,125.04 | $1,725.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,301.55 / $3,301.55 / $3,458.76
| Facility | | $3,301.55 | $3,301.55 | $3,458.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.24 / $779.92 / $1,232.86
| Professional | | $726.24 | $779.92 | $1,232.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,167.24 / $10,167.24 / $10,167.24
| Facility | | $10,167.24 | $10,167.24 | $10,167.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.26 / $1,081.50 / $1,556.11
| Professional | | $768.26 | $1,081.50 | $1,556.11 |