- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.34 / $592.05 / $3,599.72
| Facility | | $531.34 | $592.05 | $3,599.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.05 / $592.05 / $607.24
| Professional | | $592.05 | $592.05 | $607.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,808.35 / $5,808.35 / $5,808.35
| Facility | | $5,808.35 | $5,808.35 | $5,808.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.05 / $759.05 / $1,038.00
| Professional | | $759.05 | $759.05 | $1,038.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,379.49 / $1,869.91 / $4,327.93
| Facility | | $1,379.49 | $1,869.91 | $4,327.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $584.47 / $759.05 / $812.18
| Facility | | $584.47 | $759.05 | $812.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.80 / $417.48 / $691.20
| Professional | | $318.80 | $417.48 | $691.20 |