- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,047.13 / $1,995.26
| Facility | | $416.87 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $660.69 / $3,467.37
| Professional | | $169.82 | $660.69 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $457.09 / $3,311.31
| Professional | | $204.17 | $457.09 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $588.84 / $1,659.59
| Facility | | $338.84 | $588.84 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $1,659.59 / $3,388.44
| Professional | | $177.83 | $1,659.59 | $3,388.44 |