- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.41 / $879.76 / $13,871.40
| Facility | | $554.41 | $879.76 | $13,871.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.75 / $304.55 / $410.67
| Professional | | $212.75 | $304.55 | $410.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $1,529.91 / $1,529.91
| Facility | | $1,404.00 | $1,529.91 | $1,529.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.93 / $310.50 / $521.66
| Professional | | $204.93 | $310.50 | $521.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.00 / $1,485.00 / $1,485.00
| Facility | | $1,027.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.27 / $331.27 / $754.26
| Professional | | $274.27 | $331.27 | $754.26 |