- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.36 / $64.72 / $216.26
| Professional | | $38.36 | $64.72 | $216.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.60 / $154.38 / $309.77
| Professional | | $57.60 | $154.38 | $309.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.56 / $153.19 / $427.52
| Professional | | $76.56 | $153.19 | $427.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.00 / $1,183.00 / $3,774.00
| Facility | | $437.00 | $1,183.00 | $3,774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.87 / $296.33 / $460.42
| Professional | | $188.87 | $296.33 | $460.42 |