- 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
- $128.53 / $148.07 / $203.66
| Professional | | $128.53 | $148.07 | $203.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.27 / $308.55 / $308.55
| Professional | | $262.27 | $308.55 | $308.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $216.16 / $302.14
| Professional | | $150.00 | $216.16 | $302.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,082.00
| Facility | | $1,069.00 | $1,788.00 | $4,082.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.34 / $209.44 / $300.62
| Professional | | $125.34 | $209.44 | $300.62 |