- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $331.13 / $724.44
| Professional | | $208.93 | $331.13 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $331.13 / $645.65
| Professional | | $204.17 | $331.13 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $457.09
| Facility | | $371.54 | $371.54 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $389.05 / $645.65
| Professional | | $223.87 | $389.05 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $380.19 / $630.96
| Professional | | $245.47 | $380.19 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $380.19 / $831.76
| Professional | | $218.78 | $380.19 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $363.08 / $588.84
| Professional | | $223.87 | $363.08 | $588.84 |