- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $434.60 / $804.01 / $2,074.46
| Facility | | $434.60 | $804.01 | $2,074.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.60 / $457.77 / $515.72
| Professional | | $434.60 | $457.77 | $515.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.32 / $376.65 / $579.46
| Professional | | $301.32 | $376.65 | $579.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.65 / $1,399.53 / $1,817.30
| Facility | | $376.65 | $1,399.53 | $1,817.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.17 / $291.33 / $882.79
| Professional | | $247.17 | $291.33 | $882.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.26 / $2,752.44 / $2,752.44
| Facility | | $1,008.26 | $2,752.44 | $2,752.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.37 / $347.68 / $579.46
| Professional | | $243.37 | $347.68 | $579.46 |