- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.08 / $863.12 / $1,726.25
| Facility | | $396.08 | $863.12 | $1,726.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.79 / $293.39 / $337.88
| Professional | | $163.79 | $293.39 | $337.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.29 / $3,016.92 / $4,722.57
| Facility | | $1,935.29 | $3,016.92 | $4,722.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.34 / $147.34 / $147.34
| Professional | | $147.34 | $147.34 | $147.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.39 / $293.39 / $355.01
| Facility | | $293.39 | $293.39 | $355.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.77 / $476.77 / $476.77
| Professional | | $476.77 | $476.77 | $476.77 |