- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $1,288.25 / $2,041.74
| Facility | | $229.09 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $177.83 / $275.42
| Professional | | $154.88 | $177.83 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $281.84 / $363.08
| Professional | | $186.21 | $281.84 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $851.14
| Facility | | $128.82 | $346.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $213.80 / $338.84
| Professional | | $162.18 | $213.80 | $338.84 |