- 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
- $356.64 / $365.43 / $491.55
| Professional | | $356.64 | $365.43 | $491.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.72 / $432.61 / $696.74
| Professional | | $367.72 | $432.61 | $696.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $510.00 / $737.04
| Professional | | $300.00 | $510.00 | $737.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $3,447.00 / $5,685.00
| Facility | | $2,569.00 | $3,447.00 | $5,685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.10 / $509.07 / $782.73
| Professional | | $365.10 | $509.07 | $782.73 |