- 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
- $91.44 / $150.53 / $197.68
| Professional | | $91.44 | $150.53 | $197.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.08 / $176.00 / $282.29
| Professional | | $129.08 | $176.00 | $282.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.44 / $212.58 / $407.06
| Professional | | $129.44 | $212.58 | $407.06 |
- 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
- $147.68 / $218.77 / $368.80
| Professional | | $147.68 | $218.77 | $368.80 |