- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $512.86 / $1,513.56
| Facility | | $229.09 | $512.86 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $239.88 / $288.40
| Professional | | $162.18 | $239.88 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,754.23 / $3,715.35
| Facility | | $1,230.27 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $691.83 / $1,258.93
| Professional | | $245.47 | $691.83 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $676.08 / $1,348.96
| Facility | | $416.87 | $676.08 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,202.26 / $1,202.26
| Professional | | $407.38 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,511.89 / $6,025.60
| Facility | | $660.69 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $302.00 / $524.81
| Professional | | $213.80 | $302.00 | $524.81 |