- 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
- $74.51 / $195.57 / $310.61
| Professional | | $74.51 | $195.57 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.14 / $202.52 / $325.24
| Professional | | $86.14 | $202.52 | $325.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.55 / $163.55 / $433.05
| Professional | | $119.55 | $163.55 | $433.05 |
- 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
- $191.32 / $300.18 / $500.32
| Professional | | $191.32 | $300.18 | $500.32 |