- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $2,041.74 / $2,187.76
| Facility | | $426.58 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $426.58 / $478.63
| Professional | | $251.19 | $426.58 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,905.46 / $3,235.94
| Facility | | $1,096.48 | $1,905.46 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,174.90 / $1,698.24
| Facility | | $316.23 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $446.68 / $707.95
| Facility | | $398.11 | $446.68 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,479.11 / $2,238.72
| Facility | | $371.54 | $1,479.11 | $2,238.72 |