- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $1,085.84
| Facility | | $318.22 | $318.22 | $1,085.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $5,707.27
| Professional | | $318.22 | $318.22 | $5,707.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.68 / $3,157.71 / $3,728.01
| Facility | | $1,198.68 | $3,157.71 | $3,728.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.32 / $366.12 / $366.12
| Professional | | $301.32 | $366.12 | $366.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $1,963.12
| Facility | | $318.22 | $318.22 | $1,963.12 |