- 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
- $128.82 / $169.82 / $269.15
| Professional | | $128.82 | $169.82 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $5,370.32
| Facility | | $3,311.31 | $3,981.07 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $346.74
| Professional | | $204.17 | $295.12 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $186.21 / $309.03
| Professional | | $144.54 | $186.21 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,265.80
| Facility | | $831.76 | $2,951.21 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $154.88 / $239.88
| Professional | | $114.82 | $154.88 | $239.88 |