- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.18 / $117.18 / $3,332.84
| Facility | | $117.18 | $117.18 | $3,332.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.21 / $112.64 / $232.00
| Professional | | $93.21 | $112.64 | $232.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.98 / $5,034.89 / $12,757.34
| Facility | | $1,981.98 | $5,034.89 | $12,757.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.14 / $405.18 / $405.18
| Professional | | $324.14 | $405.18 | $405.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.09 / $198.03 / $241.45
| Facility | | $134.09 | $198.03 | $241.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.46 / $728.46 / $728.46
| Professional | | $728.46 | $728.46 | $728.46 |