- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $4,073.80 / $4,570.88
| Facility | | $275.42 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $602.56 / $870.96
| Professional | | $275.42 | $602.56 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,949.84 / $7,943.28
| Professional | | $281.84 | $1,949.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $588.84 / $2,238.72
| Professional | | $269.15 | $588.84 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $676.08 / $1,412.54
| Professional | | $645.65 | $676.08 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $14,454.40 / $26,302.68
| Facility | | $2,344.23 | $14,454.40 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $562.34 / $1,348.96
| Professional | | $245.47 | $562.34 | $1,348.96 |