- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $2,290.87
| Facility | | $812.83 | $812.83 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $1,318.26
| Professional | | $676.08 | $851.14 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,023.29
| Facility | | $851.14 | $851.14 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,290.87
| Facility | | $1,380.38 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $6,309.57
| Professional | | $776.25 | $1,174.90 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $20,417.38
| Facility | | $2,884.03 | $2,884.03 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $933.25 / $1,412.54
| Professional | | $630.96 | $933.25 | $1,412.54 |