- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $4,570.88
| Facility | | $2,238.72 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $1,659.59 / $2,818.38
| Professional | | $177.83 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $1,318.26 / $3,235.94
| Professional | | $218.78 | $1,318.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $1,288.25
| Professional | | $32.36 | $33.11 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $478.63 / $3,630.78
| Professional | | $251.19 | $478.63 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $1,659.59 / $3,715.35
| Professional | | $190.55 | $1,659.59 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $2,344.23 / $3,388.44
| Professional | | $239.88 | $2,344.23 | $3,388.44 |
- 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
- $177.83 / $1,445.44 / $3,090.30
| Professional | | $177.83 | $1,445.44 | $3,090.30 |