- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.68 / $1,684.51 / $2,520.92
| Facility | | $438.68 | $1,684.51 | $2,520.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.68 / $456.22 / $552.41
| Professional | | $438.68 | $456.22 | $552.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $649.89 / $1,203.50
| Professional | | $380.19 | $649.89 | $1,203.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,150.36 / $2,244.77
| Facility | | $380.19 | $1,150.36 | $2,244.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.33 / $402.63 / $1,285.75
| Professional | | $266.33 | $402.63 | $1,285.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.04 / $2,778.28 / $2,778.28
| Facility | | $1,026.04 | $2,778.28 | $2,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,924.50 / $2,924.50 / $4,386.75
| Professional | | $2,924.50 | $2,924.50 | $4,386.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.66 / $401.17 / $796.75
| Professional | | $245.66 | $401.17 | $796.75 |