- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $2,454.66 / $4,268.68
| Facility | | $1,518.41 | $2,454.66 | $4,268.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.47 / $159.83 / $498.05
| Professional | | $59.47 | $159.83 | $498.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.16 / $183.86 / $654.64
| Professional | | $109.16 | $183.86 | $654.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.44 / $240.70 / $925.85
| Professional | | $64.44 | $240.70 | $925.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.51 / $571.99 / $912.56
| Professional | | $434.51 | $571.99 | $912.56 |