- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $218.78 / $354.81
| Professional | | $186.21 | $218.78 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,244.36 / $12,302.69
| Facility | | $4,265.80 | $7,244.36 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $251.19 / $302.00
| Professional | | $204.17 | $251.19 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $263.03 / $346.74
| Professional | | $181.97 | $263.03 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $10,715.19
| Facility | | $1,023.29 | $3,548.13 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $251.19 / $446.68
| Professional | | $177.83 | $251.19 | $446.68 |