- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,128.61 / $25,118.86
| Facility | | $1,148.15 | $5,128.61 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $5,623.41 / $11,481.54
| Professional | | $1,023.29 | $5,623.41 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,071.52
| Facility | | $812.83 | $912.01 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,479.11 / $3,801.89
| Facility | | $512.86 | $1,479.11 | $3,801.89 |