- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $575.44 / $3,162.28
| Facility | | $144.54 | $575.44 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $204.17 / $1,862.09
| Professional | | $83.18 | $204.17 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,630.27
| Professional | | $2,137.96 | $2,290.87 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $281.84 / $2,187.76
| Facility | | $144.54 | $281.84 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,238.72
| Professional | | $2,187.76 | $2,187.76 | $2,238.72 |