- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $634.70 / $717.64 / $2,310.32
| Facility | | $634.70 | $717.64 | $2,310.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.70 / $660.09 / $803.96
| Professional | | $634.70 | $660.09 | $803.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.06 / $1,117.08 / $1,667.15
| Professional | | $440.06 | $1,117.08 | $1,667.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $566.70 / $1,823.09 / $3,021.12
| Facility | | $566.70 | $1,823.09 | $3,021.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $4,079.02
| Professional | | $846.27 | $846.27 | $4,079.02 |
- 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 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $507.76 / $846.27
| Professional | | $355.43 | $507.76 | $846.27 |