- 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
- $152.53 / $170.18 / $176.29
| Professional | | $152.53 | $170.18 | $176.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.28 / $188.56 / $291.48
| Professional | | $160.28 | $188.56 | $291.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.72 / $184.57 / $334.68
| Professional | | $122.72 | $184.57 | $334.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $4,628.00 / $7,350.00
| Facility | | $2,654.00 | $4,628.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.72 / $160.96 / $274.95
| Professional | | $105.72 | $160.96 | $274.95 |