- 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
- $126.84 / $138.61 / $194.86
| Professional | | $126.84 | $138.61 | $194.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.94 / $154.06 / $253.19
| Professional | | $130.94 | $154.06 | $253.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.52 / $183.54 / $259.25
| Professional | | $107.52 | $183.54 | $259.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,602.00
| Facility | | $1,069.00 | $1,788.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $179.71 / $276.45
| Professional | | $114.54 | $179.71 | $276.45 |