- 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
- $177.83 / $426.58 / $933.25
| Professional | | $177.83 | $426.58 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $2,137.96
| Facility | | $1,348.96 | $1,584.89 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $501.19 / $1,174.90
| Professional | | $186.21 | $501.19 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,659.59 / $3,090.30
| Facility | | $630.96 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $416.87 / $870.96
| Professional | | $151.36 | $416.87 | $870.96 |