- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,238.72
| Facility | | $758.58 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $257.04 / $436.52
| Professional | | $138.04 | $257.04 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,698.24
| Facility | | $1,047.13 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $223.87 / $354.81
| Professional | | $144.54 | $223.87 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $251.19 / $457.09
| Professional | | $147.91 | $251.19 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $524.81 / $1,348.96
| Facility | | $251.19 | $524.81 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $213.80 / $354.81
| Professional | | $109.65 | $213.80 | $354.81 |