- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $1,698.24
| Facility | | $218.78 | $218.78 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $380.19 / $630.96
| Professional | | $173.78 | $380.19 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $10,471.29
| Facility | | $2,884.03 | $2,884.03 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $295.12 / $501.19
| Professional | | $186.21 | $295.12 | $501.19 |