- 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
- $134.97 / $187.53 / $258.27
| Professional | | $134.97 | $187.53 | $258.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.02 / $261.36 / $351.44
| Professional | | $183.02 | $261.36 | $351.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.54 / $293.38 / $445.12
| Professional | | $171.54 | $293.38 | $445.12 |
- 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
- $163.44 / $277.62 / $477.37
| Professional | | $163.44 | $277.62 | $477.37 |