- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $1,862.09
| Facility | | $575.44 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,548.82
| Professional | | $630.96 | $831.76 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $4,265.80
| Facility | | $2,630.27 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $1,096.48
| Professional | | $575.44 | $812.83 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $851.14 / $1,862.09
| Professional | | $588.84 | $851.14 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,737.80 / $3,090.30
| Facility | | $645.65 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,258.93
| Professional | | $549.54 | $724.44 | $1,258.93 |