- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $767.53 / $767.53 / $767.53
| Facility | | $767.53 | $767.53 | $767.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.53 / $767.53 / $996.65
| Professional | | $767.53 | $767.53 | $996.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.81 / $1,163.58 / $1,175.33
| Professional | | $1,057.81 | $1,163.58 | $1,175.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $782.41 / $1,323.92 / $1,323.92
| Facility | | $782.41 | $1,323.92 | $1,323.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.41 / $1,323.92 / $2,041.51
| Professional | | $782.41 | $1,323.92 | $2,041.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $605.96 / $1,317.41 / $5,632.19
| Facility | | $605.96 | $1,317.41 | $5,632.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.31 / $600.44 / $1,000.74
| Professional | | $415.31 | $600.44 | $1,000.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.05 / $1,323.92 / $1,668.07
| Facility | | $1,320.05 | $1,323.92 | $1,668.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.81 / $1,564.63 / $2,727.48
| Professional | | $1,100.81 | $1,564.63 | $2,727.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.32 / $600.44 / $813.36
| Professional | | $435.32 | $600.44 | $813.36 |