- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,513.56
| Facility | | $630.96 | $891.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,412.54
| Professional | | $630.96 | $891.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $3,467.37
| Facility | | $676.08 | $912.01 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $912.01 / $1,949.84
| Professional | | $891.25 | $912.01 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $6,760.83
| Facility | | $1,230.27 | $1,230.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $2,630.27
| Professional | | $891.25 | $891.25 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $2,041.74
| Facility | | $831.76 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $851.14 / $1,288.25
| Professional | | $602.56 | $851.14 | $1,288.25 |