- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,778.28
| Facility | | $758.58 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,778.28
| Professional | | $741.31 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $4,073.80
| Facility | | $794.33 | $1,071.52 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,071.52 / $2,290.87
| Professional | | $1,047.13 | $1,071.52 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $7,943.28
| Facility | | $1,380.38 | $1,380.38 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $3,090.30
| Professional | | $1,000.00 | $1,000.00 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,398.83
| Facility | | $933.25 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $977.24 / $1,479.11
| Professional | | $707.95 | $977.24 | $1,479.11 |