- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $1,230.27 / $2,041.74
| Facility | | $162.18 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $141.25 / $177.83
| Professional | | $114.82 | $141.25 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Facility | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $173.78
| Professional | | $131.83 | $131.83 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $208.93 / $234.42
| Professional | | $95.50 | $208.93 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $7,079.46
| Facility | | $977.24 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $141.25 / $245.47
| Professional | | $109.65 | $141.25 | $245.47 |