- 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
- $180.31 / $328.27 / $405.00
| Professional | | $180.31 | $328.27 | $405.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.96 / $334.16 / $377.25
| Facility | | $162.96 | $334.16 | $377.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.74 / $162.96 / $162.96
| Professional | | $117.74 | $162.96 | $162.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.91 / $287.83 / $514.32
| Professional | | $158.91 | $287.83 | $514.32 |