- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $3,548.13 / $4,365.16
| Facility | | $275.42 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $275.42 / $380.19
| Professional | | $257.04 | $275.42 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $371.54 / $741.31
| Facility | | $257.04 | $371.54 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $537.03 / $1,318.26
| Professional | | $363.08 | $537.03 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Professional | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $549.54 / $870.96
| Professional | | $354.81 | $549.54 | $870.96 |