- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.51 / $556.51 / $556.51
| Facility | | $556.51 | $556.51 | $556.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.43 / $296.51 / $573.54
| Facility | | $225.43 | $296.51 | $573.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.65 / $1,251.56 / $1,290.93
| Professional | | $1,136.65 | $1,251.56 | $1,290.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.58 / $1,429.63 / $1,787.04
| Professional | | $944.58 | $1,429.63 | $1,787.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.37 / $519.52 / $3,738.96
| Facility | | $283.37 | $519.52 | $3,738.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.29 / $472.29 / $2,274.86
| Professional | | $472.29 | $472.29 | $2,274.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.58 / $1,196.47 / $1,725.10
| Facility | | $944.58 | $1,196.47 | $1,725.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.58 / $1,549.11 / $1,967.88
| Professional | | $944.58 | $1,549.11 | $1,967.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.97 / $920.97 / $1,605.79
| Professional | | $920.97 | $920.97 | $1,605.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.68 / $472.29 / $1,534.94
| Professional | | $448.68 | $472.29 | $1,534.94 |