- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.14 / $630.14 / $630.14
| Facility | | $630.14 | $630.14 | $630.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.14 / $692.57 / $6,167.68
| Professional | | $630.14 | $692.57 | $6,167.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.54 / $1,222.54 / $1,222.54
| Facility | | $1,222.54 | $1,222.54 | $1,222.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.45 / $892.45 / $2,564.52
| Professional | | $892.45 | $892.45 | $2,564.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.14 / $1,616.37 / $2,101.28
| Professional | | $1,002.14 | $1,616.37 | $2,101.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,938.78 / $2,162.23 / $2,162.23
| Facility | | $1,938.78 | $2,162.23 | $2,162.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.27 / $1,549.89 / $2,324.84
| Professional | | $1,231.27 | $1,549.89 | $2,324.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.31 / $976.08 / $1,400.31
| Professional | | $881.31 | $976.08 | $1,400.31 |