- 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
- $157.75 / $279.56 / $419.45
| Professional | | $157.75 | $279.56 | $419.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.58 / $296.44 / $467.48
| Professional | | $174.58 | $296.44 | $467.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.36 / $352.74 / $574.24
| Professional | | $220.36 | $352.74 | $574.24 |
- 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
- $222.02 / $412.11 / $650.53
| Professional | | $222.02 | $412.11 | $650.53 |