- 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
- $223.87 / $263.03 / $489.78
| Professional | | $223.87 | $263.03 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $2,511.89
| Facility | | $1,548.82 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $288.40 / $346.74
| Professional | | $199.53 | $288.40 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $288.40 / $602.56
| Professional | | $218.78 | $288.40 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,951.21 / $4,168.69
| Facility | | $812.83 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $257.04 / $407.38
| Professional | | $186.21 | $257.04 | $407.38 |