- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,258.93 / $1,819.70
| Facility | | $616.60 | $1,258.93 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $501.19 / $575.44
| Professional | | $380.19 | $501.19 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,258.93
| Facility | | $794.33 | $1,202.26 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $933.25 / $1,318.26
| Facility | | $380.19 | $933.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $676.08 / $1,380.38
| Professional | | $302.00 | $676.08 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $630.96 / $1,412.54
| Facility | | $524.81 | $630.96 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $426.58 / $1,023.29
| Professional | | $245.47 | $426.58 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $575.44 / $691.83
| Facility | | $263.03 | $575.44 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $478.63 / $812.83
| Professional | | $245.47 | $478.63 | $812.83 |