- 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
- $94.01 / $136.22 / $186.77
| Professional | | $94.01 | $136.22 | $186.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.41 / $168.61 / $253.38
| Professional | | $118.41 | $168.61 | $253.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.18 / $192.57 / $364.84
| Professional | | $123.18 | $192.57 | $364.84 |
- 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
- $142.12 / $227.54 / $336.14
| Professional | | $142.12 | $227.54 | $336.14 |