- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.40 / $1,272.42 / $3,706.14
| Facility | | $1,122.40 | $1,272.42 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.81 / $221.55 / $297.41
| Professional | | $166.81 | $221.55 | $297.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.34 / $274.82 / $441.03
| Professional | | $174.34 | $274.82 | $441.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.09 / $382.44 / $615.92
| Professional | | $234.09 | $382.44 | $615.92 |
- 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
- $224.71 / $347.00 / $545.48
| Professional | | $224.71 | $347.00 | $545.48 |