- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $1,071.52 / $2,041.74
| Facility | | $251.19 | $1,071.52 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $229.09 / $288.40
| Professional | | $177.83 | $229.09 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,570.40
| Facility | | $1,905.46 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $229.09 / $309.03
| Professional | | $190.55 | $229.09 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $331.13 / $407.38
| Professional | | $229.09 | $331.13 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $6,025.60
| Facility | | $977.24 | $2,137.96 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $218.78 / $407.38
| Professional | | $177.83 | $218.78 | $407.38 |