- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $794.33 / $2,041.74
| Facility | | $151.36 | $794.33 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $186.21 / $275.42
| Professional | | $125.89 | $186.21 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,019.95
| Facility | | $2,187.76 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $186.21 / $275.42
| Professional | | $138.04 | $186.21 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $218.78 / $338.84
| Professional | | $144.54 | $218.78 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,412.54 / $4,677.35
| Facility | | $588.84 | $1,412.54 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $177.83 / $295.12
| Professional | | $117.49 | $177.83 | $295.12 |