- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $1,445.44
| Facility | | $616.60 | $831.76 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,380.38
| Professional | | $630.96 | $831.76 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $3,162.28
| Facility | | $630.96 | $851.14 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $851.14 / $1,905.46
| Professional | | $831.76 | $851.14 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $6,456.54
| Facility | | $1,047.13 | $1,096.48 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $2,454.71
| Professional | | $812.83 | $812.83 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,047.13 / $1,862.09
| Facility | | $660.69 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,202.26
| Professional | | $562.34 | $794.33 | $1,202.26 |