- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.43 / $448.43 / $3,659.21
| Facility | | $448.43 | $448.43 | $3,659.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.43 / $448.43 / $466.37
| Professional | | $448.43 | $448.43 | $466.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.33 / $478.33 / $2,397.62
| Professional | | $478.33 | $478.33 | $2,397.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $971.60 / $1,010.46 / $2,173.60
| Facility | | $971.60 | $1,010.46 | $2,173.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.74 / $858.52 / $4,659.43
| Professional | | $327.74 | $858.52 | $4,659.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.60 / $1,215.36 / $1,215.36
| Professional | | $687.60 | $1,215.36 | $1,215.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.12 / $269.06 / $544.09
| Professional | | $46.12 | $269.06 | $544.09 |