- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $446.68 / $954.99
| Professional | | $346.74 | $446.68 | $954.99 |
- 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
- $186.21 / $354.81 / $616.60
| Professional | | $186.21 | $354.81 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,951.21 / $4,897.79
| Facility | | $812.83 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $416.87 / $602.56
| Professional | | $295.12 | $416.87 | $602.56 |