- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $4,073.80 / $4,570.88
| Facility | | $173.78 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $407.38 / $1,122.02
| Professional | | $169.82 | $407.38 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $407.38 / $4,073.80
| Professional | | $190.55 | $407.38 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $467.74 / $831.76
| Professional | | $173.78 | $467.74 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $389.05 / $1,122.02
| Professional | | $309.03 | $389.05 | $1,122.02 |
- 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
- $346.74 / $512.86 / $1,047.13
| Professional | | $346.74 | $512.86 | $1,047.13 |