- 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
- $295.12 / $446.68 / $794.33
| Professional | | $295.12 | $446.68 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,570.88 / $6,309.57
| Facility | | $3,890.45 | $4,570.88 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $416.87 / $588.84
| Professional | | $309.03 | $416.87 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $436.52 / $954.99
| Professional | | $288.40 | $436.52 | $954.99 |
- 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
- $251.19 / $389.05 / $630.96
| Professional | | $251.19 | $389.05 | $630.96 |