- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $4,073.80 / $6,456.54
| Facility | | $407.38 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $380.19 / $1,258.93
| Professional | | $234.42 | $380.19 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $2,238.72 / $6,025.60
| Professional | | $275.42 | $2,238.72 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $457.09 / $954.99
| Professional | | $257.04 | $457.09 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $575.44 / $912.01
| Professional | | $416.87 | $575.44 | $912.01 |
- 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
- $234.42 / $457.09 / $891.25
| Professional | | $234.42 | $457.09 | $891.25 |