- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $177.83 / $389.05
| Professional | | $117.49 | $177.83 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $151.36 / $251.19
| Professional | | $117.49 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $208.93 / $302.00
| Professional | | $141.25 | $208.93 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $165.96 / $295.12
| Professional | | $112.20 | $165.96 | $295.12 |