- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,445.44 / $2,238.72
| Facility | | $616.60 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $478.63 / $870.96
| Professional | | $338.84 | $478.63 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,890.45
| Facility | | $2,454.71 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $436.52 / $562.34
| Professional | | $295.12 | $436.52 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $446.68 / $1,047.13
| Professional | | $331.13 | $446.68 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,168.69
| Facility | | $831.76 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $416.87 / $549.54
| Professional | | $309.03 | $416.87 | $549.54 |