- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,071.52 / $2,511.89
| Facility | | $537.03 | $1,071.52 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $1,659.59 / $2,398.83
| Professional | | $165.96 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,344.23
| Professional | | $1,737.80 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $363.08 / $3,311.31
| Professional | | $275.42 | $363.08 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $331.13 / $851.14
| Facility | | $128.82 | $331.13 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $1,445.44 / $3,019.95
| Professional | | $173.78 | $1,445.44 | $3,019.95 |