- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.23 / $1,558.06 / $1,558.06
| Facility | | $177.23 | $1,558.06 | $1,558.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.60 / $151.81 / $253.41
| Professional | | $126.60 | $151.81 | $253.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.74 / $1,053.86 / $1,164.72
| Facility | | $867.74 | $1,053.86 | $1,164.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.23 / $199.09 / $199.09
| Professional | | $169.23 | $199.09 | $199.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,224.34 / $2,224.34 / $2,224.34
| Facility | | $2,224.34 | $2,224.34 | $2,224.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.85 / $265.58 / $409.69
| Professional | | $234.85 | $265.58 | $409.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.44 / $437.05 / $776.98
| Professional | | $153.44 | $437.05 | $776.98 |