- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.83 / $919.83 / $919.83
| Facility | | $919.83 | $919.83 | $919.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.83 / $1,233.72 / $10,986.90
| Professional | | $919.83 | $1,233.72 | $10,986.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,050.41
| Facility | | $2,050.41 | $2,050.41 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $3,406.86
| Professional | | $1,496.80 | $1,496.80 | $3,406.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.02 / $2,509.71 / $3,262.63
| Professional | | $1,556.02 | $2,509.71 | $3,262.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,010.30 / $3,357.28 / $3,357.28
| Facility | | $3,010.30 | $3,357.28 | $3,357.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.74 / $2,406.50 / $3,609.74
| Professional | | $1,911.74 | $2,406.50 | $3,609.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.48 / $1,424.81 / $2,044.07
| Professional | | $1,286.48 | $1,424.81 | $2,044.07 |