- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $2,344.23
| Professional | | $812.83 | $1,071.52 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $6,606.93
| Facility | | $1,949.84 | $3,388.44 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $1,737.80
| Professional | | $1,174.90 | $1,318.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,495.41 / $8,128.31
| Facility | | $1,148.15 | $5,495.41 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $2,137.96
| Facility | | $912.01 | $1,096.48 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,025.60 / $7,943.28
| Facility | | $5,248.07 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $1,949.84
| Professional | | $954.99 | $1,202.26 | $1,949.84 |