- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $3,162.28
| Facility | | $436.52 | $1,412.54 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $794.33 / $2,630.27
| Professional | | $275.42 | $794.33 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $275.42 / $346.74
| Professional | | $199.53 | $275.42 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $4,897.79
| Facility | | $3,019.95 | $3,548.13 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $562.34 / $891.25
| Professional | | $190.55 | $562.34 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $436.52 / $1,148.15
| Professional | | $251.19 | $436.52 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,128.61
| Facility | | $1,122.02 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $588.84 / $1,071.52
| Professional | | $218.78 | $588.84 | $1,071.52 |