- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $208.93 / $380.19
| Professional | | $173.78 | $208.93 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $4,365.16
| Facility | | $2,754.23 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $257.04 / $309.03
| Professional | | $177.83 | $257.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $245.47 / $478.63
| Professional | | $173.78 | $245.47 | $478.63 |
- 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
- $141.25 / $199.53 / $316.23
| Professional | | $141.25 | $199.53 | $316.23 |