- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.35 / $670.35 / $670.35
| Facility | | $670.35 | $670.35 | $670.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.35 / $776.58 / $6,561.18
| Professional | | $670.35 | $776.58 | $6,561.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.55 / $1,300.55 / $1,300.55
| Facility | | $1,300.55 | $1,300.55 | $1,300.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.40 / $949.40 / $2,701.13
| Professional | | $949.40 | $949.40 | $2,701.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.10 / $1,719.52 / $2,235.37
| Professional | | $1,066.10 | $1,719.52 | $2,235.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,062.48 / $2,300.21 / $2,300.21
| Facility | | $2,062.48 | $2,300.21 | $2,300.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.82 / $1,648.80 / $2,473.19
| Professional | | $1,309.82 | $1,648.80 | $2,473.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.78 / $1,038.36 / $1,219.55
| Professional | | $797.78 | $1,038.36 | $1,219.55 |