- 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
- $338.84 / $512.86 / $933.25
| Professional | | $338.84 | $512.86 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $6,456.54
| Facility | | $3,981.07 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $588.84 / $758.58
| Professional | | $338.84 | $588.84 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $537.03 / $1,096.48
| Professional | | $338.84 | $537.03 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,737.80 / $3,388.44
| Facility | | $630.96 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $446.68 / $758.58
| Professional | | $288.40 | $446.68 | $758.58 |