- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,584.89 / $2,570.40
| Facility | | $741.31 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $1,584.89
| Professional | | $891.25 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Professional | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,454.71
| Facility | | $1,023.29 | $1,023.29 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,479.11 / $2,187.76
| Professional | | $912.01 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $32.36 / $44.67
| Professional | | $21.38 | $32.36 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,621.81 / $4,073.80
| Facility | | $630.96 | $1,621.81 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $2,041.74
| Professional | | $870.96 | $1,174.90 | $2,041.74 |