- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $3,630.78
| Facility | | $758.58 | $1,023.29 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $912.01
| Professional | | $426.58 | $575.44 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $5,370.32
| Facility | | $467.74 | $467.74 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,023.29
| Professional | | $812.83 | $812.83 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $645.65 / $707.95
| Facility | | $302.00 | $645.65 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $794.33
| Professional | | $281.84 | $354.81 | $794.33 |