- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,801.89 / $5,623.41
| Facility | | $831.76 | $3,801.89 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $1,348.96
| Professional | | $575.44 | $691.83 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $13,803.84 / $19,054.61
| Facility | | $2,187.76 | $13,803.84 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $1,122.02
| Professional | | $575.44 | $691.83 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $676.08 / $758.58
| Facility | | $602.56 | $676.08 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,071.52 / $1,479.11
| Facility | | $691.83 | $1,071.52 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $776.25 / $1,230.27
| Professional | | $602.56 | $776.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $6,456.54
| Facility | | $2,570.40 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $691.83 / $1,174.90
| Professional | | $512.86 | $691.83 | $1,174.90 |