- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $776.25 / $1,288.25
| Facility | | $630.96 | $776.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $776.25 / $1,288.25
| Professional | | $630.96 | $776.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $3,090.30
| Facility | | $812.83 | $1,122.02 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,905.46
| Professional | | $812.83 | $1,096.48 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $6,309.57
| Facility | | $851.14 | $851.14 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $2,238.72
| Professional | | $724.44 | $724.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,047.13 / $1,819.70
| Facility | | $660.69 | $1,047.13 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $741.31 / $1,148.15
| Professional | | $549.54 | $741.31 | $1,148.15 |