- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $3,706.14 / $6,064.80
| Facility | | $1,518.41 | $3,706.14 | $6,064.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.80 / $216.05 / $278.13
| Professional | | $153.80 | $216.05 | $278.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.14 / $265.92 / $426.95
| Professional | | $168.14 | $265.92 | $426.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.07 / $370.25 / $606.17
| Professional | | $226.07 | $370.25 | $606.17 |
- 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
- $214.56 / $303.51 / $529.71
| Professional | | $214.56 | $303.51 | $529.71 |