- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.70 / $629.45 / $2,026.40
| Facility | | $556.70 | $629.45 | $2,026.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.70 / $578.97 / $630.92
| Professional | | $556.70 | $578.97 | $630.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.98 / $979.80 / $1,462.27
| Professional | | $385.98 | $979.80 | $1,462.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.07 / $1,598.95 / $2,650.49
| Facility | | $497.07 | $1,598.95 | $2,650.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.27 / $742.27 / $3,577.74
| Professional | | $742.27 | $742.27 | $3,577.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.55 / $3,525.78 / $3,525.78
| Facility | | $1,291.55 | $3,525.78 | $3,525.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,711.35 / $3,711.35 / $5,567.03
| Professional | | $3,711.35 | $3,711.35 | $5,567.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $445.36 / $445.36 / $742.27
| Facility | | $445.36 | $445.36 | $742.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.75 / $445.36 / $742.27
| Professional | | $311.75 | $445.36 | $742.27 |