- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,318.26 / $3,467.37
| Facility | | $630.96 | $1,318.26 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $616.60 / $851.14
| Professional | | $501.19 | $616.60 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $3,630.78
| Facility | | $758.58 | $1,202.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $575.44 / $1,202.26
| Professional | | $501.19 | $575.44 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,288.25 / $3,311.31
| Facility | | $489.78 | $1,288.25 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $2,089.30
| Professional | | $870.96 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $758.58 / $912.01
| Facility | | $457.09 | $758.58 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $457.09 / $912.01
| Professional | | $316.23 | $457.09 | $912.01 |