- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,023.29 / $1,071.52
| Facility | | $331.13 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $426.58 / $645.65
| Professional | | $257.04 | $426.58 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,023.29 / $1,071.52
| Facility | | $331.13 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $426.58 / $575.44
| Professional | | $257.04 | $426.58 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $4,265.80 / $4,786.30
| Facility | | $81.28 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $204.17 / $512.86
| Professional | | $162.18 | $204.17 | $512.86 |