- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,949.84
| Professional | | $776.25 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $2,041.74
| Professional | | $1,096.48 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $5,495.41
| Facility | | $758.58 | $1,122.02 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $2,290.87
| Professional | | $588.84 | $1,000.00 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $2,041.74
| Facility | | $1,148.15 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $831.76 / $1,318.26
| Professional | | $588.84 | $831.76 | $1,318.26 |