- 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
- $288.40 / $338.84 / $588.84
| Professional | | $288.40 | $338.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,041.74
| Facility | | $1,258.93 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $295.12 / $354.81
| Professional | | $208.93 | $295.12 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $316.23 / $758.58
| Professional | | $269.15 | $316.23 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,737.80 / $3,090.30
| Facility | | $645.65 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $275.42 / $457.09
| Professional | | $223.87 | $275.42 | $457.09 |