- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $4,073.80 / $7,762.47
| Facility | | $275.42 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $263.03 / $741.31
| Professional | | $239.88 | $263.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $1,659.59 / $4,073.80
| Professional | | $288.40 | $1,659.59 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $380.19 / $724.44
| Professional | | $263.03 | $380.19 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $524.81 / $602.56
| Professional | | $263.03 | $524.81 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $6,606.93 / $26,302.68
| Facility | | $1,023.29 | $6,606.93 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $354.81 / $741.31
| Professional | | $213.80 | $354.81 | $741.31 |