- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,318.26 / $1,995.26
| Facility | | $645.65 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $1,949.84
| Professional | | $912.01 | $1,096.48 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,258.93 / $3,388.44
| Facility | | $549.54 | $1,258.93 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $1,949.84
| Professional | | $912.01 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,238.72 / $5,623.41
| Facility | | $758.58 | $2,238.72 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $2,398.83
| Professional | | $870.96 | $1,148.15 | $2,398.83 |