- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $4,053.40
| Facility | | $496.74 | $496.74 | $4,053.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $516.61
| Professional | | $496.74 | $496.74 | $516.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.86 / $529.86 / $529.86
| Professional | | $529.86 | $529.86 | $529.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,119.33 / $2,107.09 / $2,408.10
| Facility | | $1,119.33 | $2,107.09 | $2,408.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.77 / $768.77 / $844.89
| Professional | | $768.77 | $768.77 | $844.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.67 / $1,346.30 / $1,346.30
| Professional | | $761.67 | $1,346.30 | $1,346.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.17 / $397.39 / $1,053.08
| Professional | | $278.17 | $397.39 | $1,053.08 |