- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $2,115.67
| Facility | | $846.27 | $846.27 | $2,115.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.48 / $685.48 / $846.27
| Professional | | $685.48 | $685.48 | $846.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.94 / $1,244.02 / $6,054.89
| Facility | | $818.94 | $1,244.02 | $6,054.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.51 / $338.51 / $803.95
| Professional | | $338.51 | $338.51 | $803.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,805.09 / $1,805.09 / $1,805.09
| Facility | | $1,805.09 | $1,805.09 | $1,805.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.07 / $856.34 / $1,048.20
| Professional | | $536.07 | $856.34 | $1,048.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $854.73
| Professional | | $846.27 | $846.27 | $854.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $846.27 / $2,115.67
| Facility | | $846.27 | $846.27 | $2,115.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.48 / $846.27 / $846.27
| Professional | | $685.48 | $846.27 | $846.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.76 / $507.76 / $1,269.41
| Professional | | $507.76 | $507.76 | $1,269.41 |