- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.36 / $724.36 / $724.36
| Facility | | $724.36 | $724.36 | $724.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.04 / $724.36 / $724.36
| Professional | | $678.04 | $724.36 | $724.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.63 / $780.63 / $2,446.92
| Professional | | $780.63 | $780.63 | $2,446.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,973.10 / $2,777.41 / $6,056.46
| Facility | | $1,973.10 | $2,777.41 | $6,056.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.79 / $798.71 / $3,505.54
| Professional | | $614.79 | $798.71 | $3,505.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.24 / $1,813.88 / $1,813.88
| Professional | | $840.24 | $1,813.88 | $1,813.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.88 / $1,068.13 / $2,571.64
| Professional | | $537.88 | $1,068.13 | $2,571.64 |