- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.45 / $3,095.19 / $3,751.49
| Facility | | $762.45 | $3,095.19 | $3,751.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.70 / $726.57 / $762.45
| Professional | | $588.70 | $726.57 | $762.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.66 / $699.66 / $699.66
| Professional | | $699.66 | $699.66 | $699.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.54 / $1,166.09 / $2,976.21
| Facility | | $600.54 | $1,166.09 | $2,976.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.84 / $1,030.84 / $1,288.56
| Professional | | $1,030.84 | $1,030.84 | $1,288.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.62 / $529.23 / $1,214.54
| Professional | | $412.62 | $529.23 | $1,214.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $998.81 / $2,543.00 / $3,751.49
| Facility | | $998.81 | $2,543.00 | $3,751.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.70 / $735.54 / $3,704.61
| Professional | | $588.70 | $735.54 | $3,704.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.54 / $1,166.09 / $2,976.21
| Facility | | $600.54 | $1,166.09 | $2,976.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.84 / $1,030.84 / $1,288.56
| Professional | | $1,030.84 | $1,030.84 | $1,288.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.74 / $538.20 / $1,560.78
| Professional | | $376.74 | $538.20 | $1,560.78 |