- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $4,073.80 / $4,570.88
| Facility | | $263.03 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $363.08 / $831.76
| Professional | | $245.47 | $363.08 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,659.59 / $6,456.54
| Professional | | $281.84 | $1,659.59 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $467.74 / $954.99
| Professional | | $263.03 | $467.74 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $588.84 / $933.25
| Professional | | $407.38 | $588.84 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,489.63 / $26,302.68
| Facility | | $2,344.23 | $13,489.63 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $512.86 / $977.24
| Professional | | $263.03 | $512.86 | $977.24 |