- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.20 / $555.20 / $2,824.50
| Facility | | $555.20 | $555.20 | $2,824.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.20 / $555.20 / $610.72
| Professional | | $555.20 | $555.20 | $610.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.26 / $628.54 / $628.54
| Facility | | $534.26 | $628.54 | $628.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.11 / $628.53 / $3,197.61
| Professional | | $597.11 | $628.53 | $3,197.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.20 / $555.20 / $555.20
| Facility | | $555.20 | $555.20 | $555.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.20 / $1,410.75 / $4,307.55
| Professional | | $555.20 | $1,410.75 | $4,307.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,079.08 / $3,356.53 / $5,225.33
| Facility | | $1,079.08 | $3,356.53 | $5,225.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,697.36 / $2,824.50 / $2,824.50
| Professional | | $2,697.36 | $2,824.50 | $2,824.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,242.46 / $3,356.53 / $4,307.55
| Facility | | $1,242.46 | $3,356.53 | $4,307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.46 / $3,356.53 / $4,307.55
| Professional | | $1,242.46 | $3,356.53 | $4,307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.44 / $555.20 / $2,109.76
| Professional | | $527.44 | $555.20 | $2,109.76 |