- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $2,290.87
| Facility | | $851.14 | $851.14 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $933.25
| Professional | | $660.69 | $812.83 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,148.15
| Facility | | $933.25 | $933.25 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Professional | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,290.87
| Facility | | $1,513.56 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,096.48 / $4,570.88
| Professional | | $741.31 | $1,096.48 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $8,128.31
| Facility | | $2,454.71 | $2,454.71 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,288.25
| Professional | | $691.83 | $912.01 | $1,288.25 |