- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $851.14 / $3,090.30
| Facility | | $107.15 | $851.14 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $158.49 / $562.34
| Professional | | $75.86 | $158.49 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,454.71
| Facility | | $1,202.26 | $1,621.81 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $512.86 / $724.44
| Professional | | $165.96 | $512.86 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $524.81 / $1,202.26
| Professional | | $199.53 | $524.81 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $501.19 / $602.56
| Professional | | $363.08 | $501.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $123.03 / $602.56
| Professional | | $72.44 | $123.03 | $602.56 |