- 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
- $407.38 / $537.03 / $812.83
| Professional | | $407.38 | $537.03 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $3,388.44
| Facility | | $2,089.30 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $645.65 / $776.25
| Professional | | $446.68 | $645.65 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $562.34 / $831.76
| Professional | | $331.13 | $562.34 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,365.16
| Facility | | $831.76 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $478.63 / $741.31
| Professional | | $346.74 | $478.63 | $741.31 |