- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,089.30 / $5,011.87
| Facility | | $758.58 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $223.87 / $562.34
| Professional | | $128.82 | $223.87 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,467.37 / $4,466.84
| Facility | | $1,513.56 | $3,467.37 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $154.88 / $186.21
| Professional | | $154.88 | $154.88 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $147.91 / $147.91
| Professional | | $75.86 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $56.23 / $263.03
| Professional | | $43.65 | $56.23 | $263.03 |