- 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
- $239.88 / $281.84 / $524.81
| Professional | | $239.88 | $281.84 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $4,570.88
| Facility | | $2,818.38 | $3,311.31 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $323.59 / $416.87
| Professional | | $234.42 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $331.13 / $602.56
| Professional | | $245.47 | $331.13 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,698.24 / $3,388.44
| Facility | | $630.96 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $281.84 / $457.09
| Professional | | $199.53 | $281.84 | $457.09 |