- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,071.52 / $2,630.27
| Facility | | $467.74 | $1,071.52 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $776.25
| Professional | | $512.86 | $602.56 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $630.96 / $1,047.13
| Professional | | $575.44 | $630.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $512.86 / $1,230.27
| Professional | | $426.58 | $512.86 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $467.74 / $724.44
| Facility | | $446.68 | $467.74 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,698.24
| Professional | | $549.54 | $724.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $5,128.61
| Professional | | $3,801.89 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $512.86 / $831.76
| Professional | | $323.59 | $512.86 | $831.76 |