- 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
- $133.36 / $193.20 / $259.42
| Professional | | $133.36 | $193.20 | $259.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.17 / $254.48 / $350.30
| Professional | | $166.17 | $254.48 | $350.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.31 / $250.00 / $434.74
| Professional | | $150.31 | $250.00 | $434.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.62 / $271.14 / $467.66
| Professional | | $169.62 | $271.14 | $467.66 |