- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.03 / $967.26 / $2,383.98
| Facility | | $496.03 | $967.26 | $2,383.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.78 / $471.02 / $496.87
| Professional | | $416.78 | $471.02 | $496.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.41 / $615.77 / $1,241.58
| Facility | | $407.41 | $615.77 | $1,241.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.75 / $541.80 / $759.37
| Professional | | $291.75 | $541.80 | $759.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.96 / $250.07 / $427.20
| Professional | | $172.96 | $250.07 | $427.20 |