- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $2,187.76 / $7,585.78
| Facility | | $288.40 | $2,187.76 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $251.19 / $724.44
| Professional | | $165.96 | $251.19 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,786.30 / $13,803.84
| Facility | | $2,570.40 | $4,786.30 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $251.19 / $478.63
| Professional | | $162.18 | $251.19 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $524.81 / $1,445.44
| Facility | | $34.67 | $524.81 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $295.12 / $602.56
| Professional | | $186.21 | $295.12 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,202.26 / $3,630.78
| Facility | | $295.12 | $1,202.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $245.47 / $426.58
| Professional | | $158.49 | $245.47 | $426.58 |