- 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
- $142.10 / $230.79 / $373.06
| Professional | | $142.10 | $230.79 | $373.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.56 / $286.94 / $459.78
| Professional | | $173.56 | $286.94 | $459.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.43 / $330.18 / $550.08
| Professional | | $222.43 | $330.18 | $550.08 |
- 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
- $210.22 / $389.55 / $595.10
| Professional | | $210.22 | $389.55 | $595.10 |