- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $4,365.16
| Facility | | $891.25 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $3,090.30 / $3,311.31
| Professional | | $660.69 | $3,090.30 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $398.11 / $602.56
| Facility | | $190.55 | $398.11 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $676.08 / $1,202.26
| Facility | | $489.78 | $676.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $446.68 / $1,202.26
| Facility | | $177.83 | $446.68 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |