- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.55 / $1,922.81 / $3,332.98
| Facility | | $290.55 | $1,922.81 | $3,332.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.33 / $666.43 / $5,224.29
| Professional | | $219.33 | $666.43 | $5,224.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.59 / $257.33 / $294.13
| Professional | | $254.59 | $257.33 | $294.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,454.16 / $4,454.16 / $4,454.16
| Facility | | $4,454.16 | $4,454.16 | $4,454.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.47 / $2,479.98 / $6,455.59
| Professional | | $251.47 | $2,479.98 | $6,455.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.55 / $3,563.69 / $6,671.28
| Professional | | $2,762.55 | $3,563.69 | $6,671.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,094.09 / $4,657.41 / $6,990.71
| Professional | | $3,094.09 | $4,657.41 | $6,990.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.55 / $3,176.93 / $3,908.02
| Professional | | $2,762.55 | $3,176.93 | $3,908.02 |