- 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
- $132.12 / $186.55 / $258.30
| Professional | | $132.12 | $186.55 | $258.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.36 / $229.50 / $343.40
| Professional | | $142.36 | $229.50 | $343.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.43 / $264.10 / $502.04
| Professional | | $174.43 | $264.10 | $502.04 |
- 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
- $201.23 / $252.74 / $461.91
| Professional | | $201.23 | $252.74 | $461.91 |