- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.08 / $766.08 / $766.08
| Facility | | $766.08 | $766.08 | $766.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.08 / $1,027.50 / $9,150.36
| Professional | | $766.08 | $1,027.50 | $9,150.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.28 / $1,486.28 / $1,486.28
| Facility | | $1,486.28 | $1,486.28 | $1,486.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,486.28 / $1,621.68
| Professional | | $1,084.98 | $1,486.28 | $1,621.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.02 / $2,053.26 / $2,669.23
| Professional | | $1,273.02 | $2,053.26 | $2,669.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,462.81 / $2,746.67 / $2,746.67
| Facility | | $2,462.81 | $2,746.67 | $2,746.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.05 / $1,968.81 / $2,953.22
| Professional | | $1,564.05 | $1,968.81 | $2,953.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.89 / $1,428.89 / $1,428.89
| Facility | | $1,428.89 | $1,428.89 | $1,428.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.44 / $1,186.65 / $1,702.40
| Professional | | $1,071.44 | $1,186.65 | $1,702.40 |