- 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
- $103.36 / $156.37 / $204.77
| Professional | | $103.36 | $156.37 | $204.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.38 / $224.89 / $294.45
| Professional | | $163.38 | $224.89 | $294.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.12 / $266.14 / $409.81
| Professional | | $145.12 | $266.14 | $409.81 |
- 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
- $153.08 / $249.02 / $397.33
| Professional | | $153.08 | $249.02 | $397.33 |