- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,905.46
| Facility | | $812.83 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,698.24
| Professional | | $831.76 | $1,023.29 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $3,981.07
| Facility | | $812.83 | $1,096.48 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $2,511.89
| Professional | | $1,047.13 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $7,585.78
| Facility | | $1,318.26 | $1,318.26 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $2,951.21
| Professional | | $954.99 | $954.99 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,348.96 / $2,398.83
| Facility | | $741.31 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,548.82
| Professional | | $741.31 | $1,047.13 | $1,548.82 |