- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.38 / $507.38 / $4,140.18
| Facility | | $507.38 | $507.38 | $4,140.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.38 / $507.38 / $527.66
| Professional | | $507.38 | $507.38 | $527.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.20 / $541.20 / $541.20
| Professional | | $541.20 | $541.20 | $541.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,099.33 / $1,143.30 / $2,459.29
| Facility | | $1,099.33 | $1,143.30 | $2,459.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.75 / $2,139.71 / $5,271.51
| Professional | | $407.75 | $2,139.71 | $5,271.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.98 / $1,375.12 / $1,375.12
| Professional | | $777.98 | $1,375.12 | $1,375.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.81 / $169.73 / $615.60
| Professional | | $118.81 | $169.73 | $615.60 |