- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,454.71 / $6,606.93
| Facility | | $758.58 | $2,454.71 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $281.84 / $407.38
| Professional | | $234.42 | $281.84 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $281.84 / $1,202.26
| Facility | | $199.53 | $281.84 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $331.13 / $2,137.96
| Professional | | $251.19 | $331.13 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $630.96 / $1,659.59
| Facility | | $138.04 | $630.96 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $316.23 / $478.63
| Professional | | $234.42 | $316.23 | $478.63 |