- 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
- $113.46 / $177.21 / $218.80
| Professional | | $113.46 | $177.21 | $218.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.78 / $210.38 / $324.86
| Professional | | $156.78 | $210.38 | $324.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.69 / $246.90 / $472.42
| Professional | | $156.69 | $246.90 | $472.42 |
- 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
- $175.41 / $294.64 / $434.68
| Professional | | $175.41 | $294.64 | $434.68 |