- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.02 / $677.02 / $1,404.81
| Facility | | $677.02 | $677.02 | $1,404.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.77 / $677.02 / $719.33
| Professional | | $562.77 | $677.02 | $719.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.04 / $825.12 / $2,221.40
| Facility | | $643.04 | $825.12 | $2,221.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.02 / $846.27 / $1,269.41
| Facility | | $677.02 | $846.27 | $1,269.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.08 / $550.08 / $846.27
| Professional | | $550.08 | $550.08 | $846.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.90 / $1,294.79 / $1,620.61
| Professional | | $930.90 | $1,294.79 | $1,620.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.14 / $507.76 / $871.66
| Professional | | $423.14 | $507.76 | $871.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.51 / $4,019.78 / $4,019.78
| Facility | | $1,472.51 | $4,019.78 | $4,019.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,214.42 / $4,214.42 / $6,347.03
| Professional | | $4,214.42 | $4,214.42 | $6,347.03 |