- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $8,756.45
| Facility | | $2,090.73 | $3,706.14 | $8,756.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.08 / $332.92 / $817.32
| Professional | | $101.08 | $332.92 | $817.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.28 / $320.56 / $604.26
| Professional | | $129.28 | $320.56 | $604.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.08 / $271.58 / $1,084.51
| Professional | | $177.08 | $271.58 | $1,084.51 |
- 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
- $301.94 / $663.44 / $1,151.26
| Professional | | $301.94 | $663.44 | $1,151.26 |