- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.36 / $710.36 / $710.36
| Facility | | $710.36 | $710.36 | $710.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.36 / $804.58 / $6,797.73
| Professional | | $710.36 | $804.58 | $6,797.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.14 / $1,618.14 / $1,618.14
| Facility | | $1,618.14 | $1,618.14 | $1,618.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.24 / $1,618.14 / $2,837.63
| Professional | | $1,181.24 | $1,618.14 | $2,837.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.44 / $1,850.71 / $2,405.92
| Professional | | $1,147.44 | $1,850.71 | $2,405.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.84 / $2,475.71 / $2,475.71
| Facility | | $2,219.84 | $2,475.71 | $2,475.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.75 / $1,774.59 / $2,661.89
| Professional | | $1,409.75 | $1,774.59 | $2,661.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.55 / $1,100.33 / $1,292.32
| Professional | | $861.55 | $1,100.33 | $1,292.32 |