- 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
- $68.12 / $121.29 / $207.21
| Professional | | $68.12 | $121.29 | $207.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.40 / $142.63 / $208.55
| Professional | | $80.40 | $142.63 | $208.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.57 / $154.76 / $295.50
| Professional | | $95.57 | $154.76 | $295.50 |
- 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
- $121.02 / $198.68 / $325.41
| Professional | | $121.02 | $198.68 | $325.41 |