- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.58 / $1,156.65 / $3,333.65
| Facility | | $172.58 | $1,156.65 | $3,333.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.25 / $630.97 / $927.25
| Professional | | $161.25 | $630.97 | $927.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,867.33 / $2,260.55 / $3,041.17
| Facility | | $1,867.33 | $2,260.55 | $3,041.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.52 / $860.19 / $1,402.25
| Professional | | $202.52 | $860.19 | $1,402.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.94 / $794.68 / $1,473.59
| Professional | | $192.94 | $794.68 | $1,473.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.00 / $1,738.00 / $3,362.00
| Facility | | $625.00 | $1,738.00 | $3,362.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.38 / $975.36 / $1,509.03
| Professional | | $661.38 | $975.36 | $1,509.03 |