- 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
- $182.96 / $256.61 / $336.96
| Professional | | $182.96 | $256.61 | $336.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.43 / $322.27 / $448.32
| Professional | | $223.43 | $322.27 | $448.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.70 / $320.52 / $537.61
| Professional | | $202.70 | $320.52 | $537.61 |
- 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
- $208.08 / $372.65 / $568.34
| Professional | | $208.08 | $372.65 | $568.34 |