- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.81 / $463.81 / $1,192.64
| Facility | | $463.81 | $463.81 | $1,192.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.81 / $463.81 / $622.83
| Professional | | $463.81 | $463.81 | $622.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.51 / $1,335.10 / $1,498.26
| Professional | | $1,101.51 | $1,335.10 | $1,498.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.16 / $768.77 / $966.67
| Professional | | $761.16 | $768.77 | $966.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.81 / $788.48 / $3,147.26
| Facility | | $463.81 | $788.48 | $3,147.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.27 / $662.58 / $1,126.39
| Professional | | $278.27 | $662.58 | $1,126.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.27 / $337.92 / $927.61
| Professional | | $278.27 | $337.92 | $927.61 |