- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $3,467.37
| Facility | | $467.74 | $467.74 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $426.58 / $630.96
| Professional | | $363.08 | $426.58 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $53,703.18
| Facility | | $8,511.38 | $8,511.38 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $691.83 / $1,122.02
| Professional | | $489.78 | $691.83 | $1,122.02 |