- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,238.72
| Facility | | $758.58 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $239.88 / $426.58
| Professional | | $181.97 | $239.88 | $426.58 |
- 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
- $173.78 / $251.19 / $295.12
| Professional | | $173.78 | $251.19 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $263.03 / $398.11
| Professional | | $177.83 | $263.03 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $4,073.80
| Facility | | $831.76 | $2,884.03 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $213.80 / $323.59
| Professional | | $151.36 | $213.80 | $323.59 |