- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $730.09 / $744.41 / $744.41
| Facility | | $730.09 | $744.41 | $744.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.74 / $744.41 / $1,278.88
| Professional | | $602.74 | $744.41 | $1,278.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.75 / $1,546.43 / $1,546.43
| Professional | | $1,023.75 | $1,546.43 | $1,546.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $688.86 / $908.11 / $908.11
| Facility | | $688.86 | $908.11 | $908.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.92 / $662.92 / $908.11
| Professional | | $662.92 | $662.92 | $908.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,319.64 / $6,807.72 / $6,807.72
| Facility | | $2,319.64 | $6,807.72 | $6,807.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,505.34 / $8,505.34 / $9,665.18
| Professional | | $8,505.34 | $8,505.34 | $9,665.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.76 / $849.57 / $1,008.62
| Professional | | $535.76 | $849.57 | $1,008.62 |