- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.77 / $568.77 / $4,641.16
| Facility | | $568.77 | $568.77 | $4,641.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.77 / $568.77 / $591.52
| Professional | | $568.77 | $568.77 | $591.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.52 / $758.36 / $3,698.18
| Professional | | $682.52 | $758.36 | $3,698.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.33 / $1,281.61 / $2,756.88
| Facility | | $1,232.33 | $1,281.61 | $2,756.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $2,399.14 / $5,907.87
| Professional | | $457.09 | $2,399.14 | $5,907.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.11 / $1,541.52 / $1,541.52
| Professional | | $872.11 | $1,541.52 | $1,541.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.51 / $318.51 / $318.51
| Facility | | $318.51 | $318.51 | $318.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.51 / $455.02 / $1,205.79
| Professional | | $318.51 | $455.02 | $1,205.79 |