- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $4,073.80 / $4,570.88
| Facility | | $257.04 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $354.81 / $758.58
| Professional | | $239.88 | $354.81 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,819.70 / $5,370.32
| Professional | | $275.42 | $1,819.70 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $436.52 / $933.25
| Professional | | $257.04 | $436.52 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $891.25
| Professional | | $407.38 | $575.44 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $7,762.47 / $26,302.68
| Facility | | $2,344.23 | $7,762.47 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $446.68 / $891.25
| Professional | | $234.42 | $446.68 | $891.25 |