- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.09 / $2,637.65 / $4,469.92
| Facility | | $1,167.09 | $2,637.65 | $4,469.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.05 / $930.45 / $1,167.09
| Professional | | $346.05 | $930.45 | $1,167.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $70.34 / $1,243.60
| Professional | | $38.02 | $70.34 | $1,243.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.22 / $60.22 / $60.22
| Professional | | $60.22 | $60.22 | $60.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.67 / $996.71 / $1,743.27
| Professional | | $818.67 | $996.71 | $1,743.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.18 / $1,081.40 / $1,854.40
| Professional | | $32.18 | $1,081.40 | $1,854.40 |