- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.77 / $3,695.07 / $8,918.80
| Facility | | $193.77 | $3,695.07 | $8,918.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.10 / $169.58 / $203.23
| Professional | | $153.10 | $169.58 | $203.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $677.68 / $1,389.04 / $3,604.40
| Facility | | $677.68 | $1,389.04 | $3,604.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.02 / $230.00 / $339.25
| Professional | | $192.02 | $230.00 | $339.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.40 / $311.70 / $311.70
| Professional | | $248.40 | $311.70 | $311.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.00 / $231.00 / $367.00
| Professional | | $177.00 | $231.00 | $367.00 |