- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,258.93 / $1,737.80
| Facility | | $524.81 | $1,258.93 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $281.84 / $524.81
| Professional | | $194.98 | $281.84 | $524.81 |
- 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
- $165.96 / $269.15 / $346.74
| Professional | | $165.96 | $269.15 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $309.03 / $562.34
| Professional | | $186.21 | $309.03 | $562.34 |
- 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
- $173.78 / $263.03 / $436.52
| Professional | | $173.78 | $263.03 | $436.52 |