- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.76 / $157.26 / $254.40
| Facility | | $101.76 | $157.26 | $254.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.52 / $600.29 / $1,018.30
| Professional | | $198.52 | $600.29 | $1,018.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $432.74 / $4,842.55 / $11,045.56
| Facility | | $432.74 | $4,842.55 | $11,045.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.53 / $211.79 / $305.12
| Professional | | $182.53 | $211.79 | $305.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,733.33 / $10,733.33 / $10,733.33
| Facility | | $10,733.33 | $10,733.33 | $10,733.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.30 / $193.67 / $532.95
| Professional | | $135.30 | $193.67 | $532.95 |