- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $3,706.14 / $4,224.43
| Facility | | $1,518.41 | $3,706.14 | $4,224.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.90 / $126.11 / $159.47
| Professional | | $97.90 | $126.11 | $159.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.26 / $167.01 / $241.03
| Professional | | $124.26 | $167.01 | $241.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.34 / $209.02 / $349.62
| Professional | | $142.34 | $209.02 | $349.62 |
- 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
- $118.86 / $184.62 / $310.50
| Professional | | $118.86 | $184.62 | $310.50 |