- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.43 / $760.43 / $760.43
| Facility | | $760.43 | $760.43 | $760.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.43 / $760.43 / $987.42
| Professional | | $760.43 | $760.43 | $987.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.32 / $894.32 / $894.32
| Professional | | $894.32 | $894.32 | $894.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.03 / $1,152.83 / $1,164.48
| Professional | | $1,048.03 | $1,152.83 | $1,164.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $736.69 / $958.87 / $1,311.67
| Facility | | $736.69 | $958.87 | $1,311.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.94 / $1,389.38 / $2,022.62
| Professional | | $1,275.94 | $1,389.38 | $2,022.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.37 / $1,305.22 / $5,580.24
| Facility | | $600.37 | $1,305.22 | $5,580.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.49 / $594.89 / $1,170.25
| Professional | | $411.49 | $594.89 | $1,170.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.83 / $1,311.67 / $1,652.66
| Facility | | $1,307.83 | $1,311.67 | $1,652.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.00 / $1,550.16 / $2,702.26
| Professional | | $1,171.00 | $1,550.16 | $2,702.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.49 / $594.89 / $805.86
| Professional | | $411.49 | $594.89 | $805.86 |