- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $602.56 / $8,511.38
| Facility | | $245.47 | $602.56 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $524.81 / $758.58
| Professional | | $245.47 | $524.81 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $676.08 / $1,348.96
| Professional | | $501.19 | $676.08 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $1,548.82
| Professional | | $371.54 | $758.58 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $588.84 / $1,737.80
| Facility | | $263.03 | $588.84 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $1,348.96
| Professional | | $602.56 | $933.25 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $5,128.61
| Facility | | $4,677.35 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $602.56 / $1,348.96
| Professional | | $288.40 | $602.56 | $1,348.96 |