- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $2,137.96 / $7,762.47
| Facility | | $218.78 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $194.98 / $218.78
| Professional | | $83.18 | $194.98 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $1,071.52 / $2,454.71
| Professional | | $107.15 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $234.42 / $478.63
| Professional | | $223.87 | $234.42 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,737.80 / $5,128.61
| Facility | | $741.31 | $1,737.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $239.88 / $512.86
| Professional | | $162.18 | $239.88 | $512.86 |