- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,305.84 / $2,305.84 / $5,348.46
| Facility | | $2,305.84 | $2,305.84 | $5,348.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.05 / $721.92 / $1,258.17
| Professional | | $636.05 | $721.92 | $1,258.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.20 / $989.42 / $1,519.06
| Professional | | $780.20 | $989.42 | $1,519.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.55 / $1,157.72 / $1,716.29
| Professional | | $986.55 | $1,157.72 | $1,716.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.23 / $1,191.19 / $1,764.66
| Professional | | $994.23 | $1,191.19 | $1,764.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,305.84 / $2,305.84 / $5,348.46
| Facility | | $2,305.84 | $2,305.84 | $5,348.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.04 / $783.60 / $1,484.26
| Professional | | $636.04 | $783.60 | $1,484.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.12 / $1,130.08 / $1,581.90
| Professional | | $800.12 | $1,130.08 | $1,581.90 |