- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $2,630.27 / $6,760.83
| Facility | | $331.13 | $2,630.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $295.12 / $389.05
| Professional | | $208.93 | $295.12 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $229.09
| Facility | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $331.13 / $501.19
| Professional | | $186.21 | $331.13 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $467.74 / $5,495.41
| Facility | | $208.93 | $467.74 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $331.13 / $3,235.94
| Professional | | $257.04 | $331.13 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $5,888.44
| Facility | | $891.25 | $3,235.94 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $257.04 / $363.08
| Professional | | $177.83 | $257.04 | $363.08 |