- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.43 / $312.76 / $1,400.00
| Facility | | $253.43 | $312.76 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.66 / $295.94 / $374.98
| Professional | | $238.66 | $295.94 | $374.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.48 / $318.58 / $347.10
| Facility | | $265.48 | $318.58 | $347.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.52 / $308.52 / $308.52
| Professional | | $308.52 | $308.52 | $308.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.89 / $465.89 / $465.89
| Facility | | $465.89 | $465.89 | $465.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.17 / $377.12 / $862.66
| Professional | | $260.17 | $377.12 | $862.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.23 / $1,066.23 / $1,066.23
| Facility | | $1,066.23 | $1,066.23 | $1,066.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.45 / $575.45 / $575.45
| Professional | | $575.45 | $575.45 | $575.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.56 / $422.89 / $594.39
| Professional | | $264.56 | $422.89 | $594.39 |