- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $3,162.28 / $7,762.47
| Facility | | $186.21 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $186.21 / $223.87
| Professional | | $165.96 | $186.21 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $549.54 / $2,344.23
| Professional | | $97.72 | $549.54 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $239.88 / $512.86
| Professional | | $151.36 | $239.88 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $213.80 / $549.54
| Professional | | $204.17 | $213.80 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $549.54 / $5,888.44
| Facility | | $165.96 | $549.54 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $275.42 / $588.84
| Professional | | $165.96 | $275.42 | $588.84 |