- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $2,290.87
| Facility | | $741.31 | $741.31 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,318.26
| Professional | | $630.96 | $758.58 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $933.25
| Facility | | $776.25 | $776.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $2,290.87
| Facility | | $1,258.93 | $1,258.93 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $5,248.07
| Professional | | $676.08 | $1,047.13 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $9,120.11
| Facility | | $2,884.03 | $2,884.03 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $831.76 / $1,202.26
| Professional | | $562.34 | $831.76 | $1,202.26 |