- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $1,348.96 / $1,621.81
| Facility | | $144.54 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,348.96 / $1,380.38
| Professional | | $1,288.25 | $1,348.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $346.74 / $512.86
| Facility | | $141.25 | $346.74 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,071.52 / $1,698.24
| Professional | | $125.89 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $1,380.38 / $1,380.38
| Professional | | $186.21 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,041.74 / $2,398.83
| Facility | | $1,230.27 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,318.26 / $1,348.96
| Professional | | $125.89 | $1,318.26 | $1,348.96 |