- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.76 / $1,122.58 / $1,122.58
| Facility | | $356.76 | $1,122.58 | $1,122.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.58 / $1,122.58 / $2,452.69
| Professional | | $1,122.58 | $1,122.58 | $2,452.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.94 / $1,565.94 / $1,703.74
| Facility | | $1,565.94 | $1,565.94 | $1,703.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.14 / $486.37 / $3,531.44
| Facility | | $317.14 | $486.37 | $3,531.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.12 / $369.83 / $460.95
| Professional | | $229.12 | $369.83 | $460.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.35 / $1,538.93 / $4,467.37
| Professional | | $261.35 | $1,538.93 | $4,467.37 |