- 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
- $104.71 / $133.09 / $164.87
| Professional | | $104.71 | $133.09 | $164.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.07 / $184.19 / $250.44
| Professional | | $125.07 | $184.19 | $250.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.08 / $228.55 / $352.32
| Professional | | $170.08 | $228.55 | $352.32 |
- 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
- $132.63 / $185.52 / $308.20
| Professional | | $132.63 | $185.52 | $308.20 |