- 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
- $74.52 / $172.87 / $281.88
| Professional | | $74.52 | $172.87 | $281.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.56 / $203.92 / $312.45
| Professional | | $89.56 | $203.92 | $312.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.37 / $170.48 / $412.07
| Professional | | $106.37 | $170.48 | $412.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.90 / $291.42 / $475.11
| Professional | | $174.90 | $291.42 | $475.11 |