- 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
- $78.84 / $134.30 / $255.86
| Professional | | $78.84 | $134.30 | $255.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.77 / $139.26 / $219.52
| Professional | | $81.77 | $139.26 | $219.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.75 / $163.83 / $290.89
| Professional | | $115.75 | $163.83 | $290.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.00 / $2,445.00 / $4,602.00
| Facility | | $1,388.00 | $2,445.00 | $4,602.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.37 / $213.30 / $399.90
| Professional | | $133.37 | $213.30 | $399.90 |