- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $5,370.32 / $7,079.46
| Facility | | $251.19 | $5,370.32 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $251.19 / $602.56
| Professional | | $177.83 | $251.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $2,570.40 / $6,456.54
| Professional | | $263.03 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $275.42 / $575.44
| Professional | | $218.78 | $275.42 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $275.42 / $588.84
| Professional | | $263.03 | $275.42 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,489.63 / $26,302.68
| Facility | | $2,344.23 | $13,489.63 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $281.84 / $588.84
| Professional | | $190.55 | $281.84 | $588.84 |