- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $2,238.72
| Facility | | $436.52 | $436.52 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $331.13 / $3,467.37
| Professional | | $51.29 | $331.13 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $676.08 / $1,698.24
| Facility | | $363.08 | $676.08 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,570.40 / $2,570.40
| Professional | | $1,288.25 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,737.80 / $5,128.61
| Facility | | $331.13 | $1,737.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $3,890.45 / $4,073.80
| Professional | | $70.79 | $3,890.45 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,570.40 / $3,715.35
| Facility | | $602.56 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |