- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $4,570.88
| Facility | | $2,238.72 | $3,388.44 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $630.96 / $2,884.03
| Professional | | $204.17 | $630.96 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $2,137.96 / $3,548.13
| Professional | | $257.04 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $60.26 / $12,022.64
| Professional | | $32.36 | $60.26 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $575.44 / $7,585.78
| Professional | | $288.40 | $575.44 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $1,288.25 / $4,570.88
| Professional | | $234.42 | $1,288.25 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,995.26 / $3,235.94
| Professional | | $281.84 | $1,995.26 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,466.84 / $5,128.61
| Facility | | $1,071.52 | $4,466.84 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $1,380.38 / $3,467.37
| Professional | | $204.17 | $1,380.38 | $3,467.37 |