- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.44 / $805.89 / $1,600.00
| Facility | | $470.44 | $805.89 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.52 / $545.52 / $850.08
| Professional | | $464.52 | $545.52 | $850.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.09 / $546.94 / $679.97
| Facility | | $520.09 | $546.94 | $679.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.07 / $604.41 / $604.41
| Professional | | $310.07 | $604.41 | $604.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $592.57 / $592.57 / $592.57
| Facility | | $592.57 | $592.57 | $592.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.88 / $637.70 / $1,470.54
| Professional | | $500.88 | $637.70 | $1,470.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.00 / $1,225.00 / $1,225.00
| Facility | | $1,225.00 | $1,225.00 | $1,225.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.89 / $502.28 / $805.89
| Professional | | $317.89 | $502.28 | $805.89 |