- 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
- $149.30 / $240.61 / $387.60
| Professional | | $149.30 | $240.61 | $387.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.01 / $258.79 / $425.93
| Professional | | $158.01 | $258.79 | $425.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.84 / $319.64 / $528.37
| Professional | | $203.84 | $319.64 | $528.37 |
- 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
- $213.33 / $342.46 / $563.64
| Professional | | $213.33 | $342.46 | $563.64 |