- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $1,862.09
| Facility | | $575.44 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $316.23 / $398.11
| Professional | | $257.04 | $316.23 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,495.41 / $7,413.10
| Facility | | $4,677.35 | $5,495.41 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Professional | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $588.84 / $1,548.82
| Facility | | $251.19 | $588.84 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $309.03 / $416.87
| Professional | | $257.04 | $309.03 | $416.87 |