- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,238.72 / $2,238.72
| Facility | | $645.65 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $2,951.21
| Facility | | $1,584.89 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $1,071.52
| Facility | | $512.86 | $645.65 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $645.65 / $1,230.27
| Facility | | $512.86 | $645.65 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $2,089.30
| Professional | | $977.24 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $3,801.89
| Facility | | $1,412.54 | $1,412.54 | $3,801.89 |