- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.43 / $384.29 / $1,319.88
| Facility | | $307.43 | $384.29 | $1,319.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.43 / $307.43 / $389.41
| Professional | | $307.43 | $307.43 | $389.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.83 / $455.45 / $865.36
| Professional | | $236.83 | $455.45 | $865.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.39 / $843.92 / $1,463.79
| Facility | | $260.39 | $843.92 | $1,463.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.90 / $409.90 / $1,975.72
| Professional | | $409.90 | $409.90 | $1,975.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.23 / $1,947.03 / $1,947.03
| Facility | | $713.23 | $1,947.03 | $1,947.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.50 / $2,049.50 / $3,074.25
| Professional | | $2,049.50 | $2,049.50 | $3,074.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.16 / $273.27 / $450.89
| Professional | | $172.16 | $273.27 | $450.89 |