- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $4,233.63
| Facility | | $2,090.73 | $3,706.14 | $4,233.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.70 / $107.94 / $142.58
| Professional | | $72.70 | $107.94 | $142.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.86 / $135.91 / $219.47
| Professional | | $86.86 | $135.91 | $219.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.92 / $165.67 / $308.93
| Professional | | $87.92 | $165.67 | $308.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.12 / $192.84 / $270.73
| Professional | | $116.12 | $192.84 | $270.73 |