- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $567.16 / $743.97 / $15,028.20
| Facility | | $567.16 | $743.97 | $15,028.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.19 / $625.95 / $743.97
| Professional | | $506.19 | $625.95 | $743.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.76 / $3,200.76 / $3,200.76
| Facility | | $3,200.76 | $3,200.76 | $3,200.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.39 / $671.86 / $1,295.28
| Professional | | $515.39 | $671.86 | $1,295.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,776.22 / $4,776.22 / $4,776.22
| Facility | | $4,776.22 | $4,776.22 | $4,776.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.00 / $1,320.00 / $1,320.00
| Facility | | $1,320.00 | $1,320.00 | $1,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.00 / $755.47 / $1,641.18
| Professional | | $607.00 | $755.47 | $1,641.18 |