- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $776.25 / $8,511.38
| Facility | | $295.12 | $776.25 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $1,047.13
| Professional | | $295.12 | $295.12 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $758.58 / $1,047.13
| Facility | | $295.12 | $758.58 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $758.58 / $1,288.25
| Professional | | $467.74 | $758.58 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $758.58 / $1,023.29
| Professional | | $467.74 | $758.58 | $1,023.29 |