- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,778.28 / $3,467.37
| Facility | | $512.86 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $575.44 / $724.44
| Professional | | $512.86 | $575.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $21,379.62 / $21,379.62
| Facility | | $21,379.62 | $21,379.62 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $776.25 / $1,023.29
| Professional | | $724.44 | $776.25 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,819.70 / $4,168.69
| Facility | | $467.74 | $1,819.70 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $1,230.27
| Facility | | $549.54 | $616.60 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $870.96
| Facility | | $645.65 | $724.44 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $724.44
| Professional | | $302.00 | $436.52 | $724.44 |