- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.02 / $1,040.23 / $1,607.36
| Facility | | $554.02 | $1,040.23 | $1,607.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.55 / $437.96 / $503.40
| Professional | | $377.55 | $437.96 | $503.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.25 / $629.25 / $629.25
| Professional | | $629.25 | $629.25 | $629.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.86 / $530.08 / $1,141.83
| Facility | | $330.86 | $530.08 | $1,141.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.20 / $583.98 / $734.31
| Professional | | $578.20 | $583.98 | $734.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.04 / $412.79 / $875.92
| Facility | | $302.04 | $412.79 | $875.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $302.04 / $855.78
| Professional | | $211.43 | $302.04 | $855.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.04 / $302.04 / $503.40
| Facility | | $302.04 | $302.04 | $503.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $302.04 / $855.78
| Professional | | $211.43 | $302.04 | $855.78 |