- 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 / $20,286.65
| Facility | | $818.94 | $1,244.02 | $20,286.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.51 / $338.51 / $2,559.01
| Professional | | $338.51 | $338.51 | $2,559.01 |
- 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 / $894.20
| Professional | | $536.07 | $856.34 | $894.20 |
- 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
- $431.60 / $507.76 / $1,480.97
| Professional | | $431.60 | $507.76 | $1,480.97 |