- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,412.54 / $2,041.74
| Facility | | $575.44 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $1,023.29
| Professional | | $630.96 | $707.95 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,630.78
| Facility | | $2,630.27 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $977.24
| Professional | | $741.31 | $741.31 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $851.14 / $1,202.26
| Professional | | $588.84 | $851.14 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $5,248.07
| Facility | | $588.84 | $1,445.44 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,288.25
| Professional | | $549.54 | $724.44 | $1,288.25 |