- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $2,570.40 / $6,025.60
| Facility | | $446.68 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $245.47 / $316.23
| Professional | | $190.55 | $245.47 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,466.84 / $6,309.57
| Facility | | $2,454.71 | $4,466.84 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $239.88 / $281.84
| Professional | | $199.53 | $239.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $269.15 / $380.19
| Professional | | $177.83 | $269.15 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,630.27 / $6,606.93
| Facility | | $831.76 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $263.03 / $436.52
| Professional | | $204.17 | $263.03 | $436.52 |