- 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
- $223.87 / $288.40 / $537.03
| Professional | | $223.87 | $288.40 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,235.94
| Facility | | $2,041.74 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $302.00 / $380.19
| Professional | | $199.53 | $302.00 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $309.03 / $676.08
| Professional | | $208.93 | $309.03 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,737.80 / $3,235.94
| Facility | | $630.96 | $1,737.80 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $263.03 / $407.38
| Professional | | $194.98 | $263.03 | $407.38 |