- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.78 / $879.78 / $879.78
| Facility | | $879.78 | $879.78 | $879.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.28 / $879.78 / $1,570.09
| Professional | | $737.28 | $879.78 | $1,570.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,459.20
| Facility | | $1,122.47 | $1,122.47 | $1,459.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.57 / $1,122.47 / $2,077.50
| Professional | | $341.57 | $1,122.47 | $2,077.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,146.35 / $3,146.35 / $3,146.35
| Professional | | $3,146.35 | $3,146.35 | $3,146.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.23 / $1,260.72 / $1,260.72
| Professional | | $78.23 | $1,260.72 | $1,260.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.94 / $1,030.46 / $1,828.14
| Professional | | $839.94 | $1,030.46 | $1,828.14 |