- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,737.80
| Facility | | $794.33 | $794.33 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $562.34 / $758.58
| Professional | | $416.87 | $562.34 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,137.96
| Facility | | $977.24 | $1,318.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $977.24 / $1,445.44
| Professional | | $467.74 | $977.24 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,288.25 / $4,466.84
| Facility | | $512.86 | $1,288.25 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,445.44 / $1,698.24
| Professional | | $812.83 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $467.74 / $1,380.38
| Professional | | $380.19 | $467.74 | $1,380.38 |