- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,454.71 / $6,606.93
| Facility | | $758.58 | $2,454.71 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $162.18 / $275.42
| Professional | | $141.25 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $199.53 / $234.42
| Professional | | $151.36 | $199.53 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $1,862.09 / $5,495.41
| Facility | | $165.96 | $1,862.09 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $177.83 / $2,137.96
| Professional | | $131.83 | $177.83 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $5,754.40
| Facility | | $891.25 | $3,235.94 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $162.18 / $229.09
| Professional | | $123.03 | $162.18 | $229.09 |