- 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
- $122.56 / $156.19 / $210.31
| Professional | | $122.56 | $156.19 | $210.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.22 / $193.98 / $289.42
| Professional | | $136.22 | $193.98 | $289.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.16 / $220.69 / $419.43
| Professional | | $142.16 | $220.69 | $419.43 |
- 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
- $164.50 / $255.50 / $440.32
| Professional | | $164.50 | $255.50 | $440.32 |