- 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 / $436.52 / $794.33
| Professional | | $338.84 | $436.52 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,786.30 / $6,456.54
| Facility | | $4,073.80 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $426.58 / $524.81
| Professional | | $263.03 | $426.58 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $457.09 / $794.33
| Professional | | $323.59 | $457.09 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,019.95 / $4,365.16
| Facility | | $831.76 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $416.87 / $630.96
| Professional | | $288.40 | $416.87 | $630.96 |