- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $3,467.37 / $4,786.30
| Facility | | $91.20 | $3,467.37 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $165.96 / $363.08
| Professional | | $79.43 | $165.96 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $87.10 / $104.71
| Facility | | $87.10 | $87.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $181.97 / $537.03
| Professional | | $87.10 | $181.97 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $8,511.38 / $9,772.37
| Facility | | $2,137.96 | $8,511.38 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $4,570.88
| Facility | | $1,230.27 | $1,230.27 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $141.25 / $281.84
| Professional | | $74.13 | $141.25 | $281.84 |